Where it came from

DBT was developed by Marsha Linehan in the early 1990s. It was a result of her frustration at trying to use traditional cognitive behaviour techniques to treat patients with severe suicidality and borderline personality disorder.

The ‘dialectical’ of DBT refers to its aim of balancing the tension between change and acceptance.

 

How difficulties originate

Linehan hypothesizes that people with BPD have a biological predisposition to emotional dysregulation. They (1) have a heightened awareness of emotional stimuli, and react to lower levels of stimulus than other people; (2) They respond more rapidly and with more intensity to the same level of emotional stimuli; (3) They are slower to return to ‘normal’ levels of emotional arousal, which leaves them more vulnerable to subsequent emotional stimuli.

Linehan proposed that this biological predisposition interacts with an invalidating environment to produce BPD. An invalidating environment is one which teaches the client that their emotions, thoughts or action urges are ‘wrong’, and rejects or punishes their communication of these experiences.

 DBT assumes that:

  • Patients are doing the best they can
  • Patients want to improve
  • Patients need to do better, try harder and be more motivated to change
  • Patients may not have caused all their own problems, but they will have to solve them nonetheless
  • Patients’ lives are unbearable as they are currently being lived
  • Patients must learn new behaviours in context
  • Patients cannot fail in therapy

 

Treatment strategy

Individual therapy: this addresses the issues which affect the client’s motivation to use skilled behaviour. Behavioural chain analyses are carried out on the most problematic behaviours of the week, which identify the problem triggers and factors. A solution analysis generates alternative behavioural solutions, which consider the skills needed, the reinforcement contingencies, and any emotion-phobia which might inhibit adaptive problem-solving.

Skills training: this is a didactical setting where clients are taught the skills of DBT. Clients then go and practise the new skills across the week, and review their progress as a group the next week. The group context of skills training minimizes the risk of being side-tracked by the client’s pressing issues, reduces the intensity of the relationship with the trainer, and provides an opportunity to observe and work with interpersonal behaviours. It also offers clients the opportunity to interact with other people with similar difficulties.

Telephone skills coaching: Learning skills in a clinic might seem simple enough, but actually using these skills in highly emotional situations and at times of great distress is difficult to do; that is, the skills do not autmoatically ‘generalize’ to the client’s life. The client therefore has telephone access to the individual therapist, who can coach her to use specific skills in the problem situation. This is not only for crises; it can be used in any situation where clients need to use skills to reach their goals. Indeed, telephone consultation is suspended for 24 hours following any incidents of self-harm or suicide attempts, to avoid reinforcing problematic behaviour. Telephone consultation also offers patients a way to repair the relationship following conflict or misunderstanding.

Team consultation: Delivering DBT is very demanding for the therapist. It is therefore important that the therapist be kept within DBT by participating in a DBT case consultion group.  

 

What are the ‘skills’?

Skills training aims to replace interpersonal dysregulation with interpersonal skills; emotional dysregulation with emotion regulation skills; behavioural and cognitive dysregulation with distress tolerance skills, and self dysregulation with core mindfulness skills.

 

Evidence base

 

 

More information

A very good introductory book on DBT is Dialectical Behaviour Therapy from the CBT Distinctive Features Series, by Swales & Heard

The original DBT ‘Bible’ is the hefty handbook by Linehan (don’t be put off by the ‘cognitive’ instead of ‘dialectical’ in the title; apparently her publishers thought ‘dialectical’ wouldn’t sell!)

Details of all the skills can be found in the DBT Skills Training Manual by Linehan

PDFs of all the research evidence can be found at Linehan’s own website, Behavior Tech