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Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT) is a form of psychotherapy that was developed for treating Borderline Personality Disorder. It is considered by some as a "third wave" or "third generation" cognitive behavioral therapy, following in the steps of Behavioral Therapy and CBT. It combines standard cognitive-behavioral techniques with concepts of mindful awareness and acceptance derived from Buddhist meditative practice.

The term "dialectical" refers to an attempt to accept multiple perspectives and to acknowledge different and at time opposing forces at play in a client's experiences and in the therapy. The main dialectic in this therapy involves balancing the goal of accepting and tolerating a certain amount of distress in one's life, with taking active steps to make important life changes [ref].

The Process of Dialectical Behavior Therapy

DBT involves highly structured individual and group therapy components, each offered on a weekly basis, with the goal of teaching the clients skills to help them gain control over their emotional and behavioral symptoms. There is a specific order or hierarchy of stages in which clients' issues and symptoms are addressed, with the most severe and potentially dangerous and destructive behaviors addressed first. Only when these issues come under a certain amount of control is the client ready to move-on to further stages.

Stage 1: This involves achieving control over unstable and dangerous behaviors, according to the following order of priority:

  1. Self-injurious and suicidal behaviors.
  2. Issues and behaviors that interfere in some way with the progress of the therapy. This includes missing appointments, phoning at unreasonable hours, or other behaviors that seemed designed to sabotage the therapy.
  3. Behaviors that interfere significantly with the client's quality of life. Examples include substance use, homelessness, and unemployment.

In order to address these issues, as well as many of the other typical problems of Borderline Personality Disorder, clients are taught various key cognitive and behavioral skills, including:

    Mindfulness: this involves trying to experience the present moment - including one's inner thoughts and feelings as well as what is happening in one's surroundings - in a way that is as direct and nonjudgmental as possible. This technique can help individuals with Borderline Personality Disorder better tolerate their powerful and unpredictable emotional reactions.

    Interpersonal effectiveness: here clients learn strategies for how to ask for what they need from others, how to best handle interpersonal conflicts, and to know when and how to say no.

    Emotion regulation: difficulties regulating one's emotions is one of the core features of Borderline Personality Disorder. Skills that can help with this problem include:

    • Learning how to identify and label emotions as they occur.
    • Identifying and overcoming obstacles that prevent one from changing one's emotions.
    • Learning how to avoid reacting to events on a purely emotional level.
    • Increasing positive emotional events.
    • Taking the opposite action of what one's emotions would dictate.

    Distress tolerance: this involves learning to accept and tolerate, in a nonjudgmental fashion, distressing and unpleasant events and situations, and to allow uncomfortable experiences to occur without immediately trying to fight them, control them or alter them. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This perspective allows individuals to make wise and healthy decisions about whether and how to take action. Individual skills of distress tolerance include:

    • Distracting oneself from a painful situation.
    • Finding healthy ways to soothe and comfort oneself.
    • Learning how to improve the moment.
    • Thinking carefully about the pros and cons of every situation.
    • Radical acceptance of even very painful situations.
    • Distinguishing between "willingness" and the ability to act skillfully with a realistic understanding of the present situation, versus "willfulness," that is, trying to impose one's will at any cost.

Stage 2: Here, the goal is to replace "quiet desperation" with more healthy and full range of emotional experiencing.

Stage 3: In this stage, the goal is to help clients overcome ongoing emotional disorders, such as depression and anxiety, as well as to resolve residual behavioral problems.

Stage 4: This involves trying to resolve the client's sense of incompleteness and to achieve the capacity for joy.

Applications of Dialectical Behavior Therapy

As mentioned above, DBT was designed specifically for treating Borderline Personality Disorder, and there is now good evidence to indicate that it is an effective treatment for this condition [ref]. Increasingly, this therapy is also being adapted to address other conditions where impulsive and self-destructive behaviors are an issue, including Substance Use Disorders, Eating Disorders, and suicidal behaviors occurring in the context of Mood Disorders [ref].