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Dialectic Behaviour Therapy

by Helena Kisand
Dialectic Behaviour Therapy is widely used in treating Borderline Personality Disorder and particularly reducing self-harm associated with this disorder.
Dialectic Behaviour Therapy
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Contributors (5)
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Published
Jun 04, 2019

Brief historical overview

In the 1980s the American psychologist Marsha Linehan, wishing to help patients with chronic suicidality, tried to take a purely behavioural approach. However, her clients frequently didn’t complete homework or didn’t return for subsequent sessions at all. Linehan hypothesised that these behaviours arose because the clients experienced the strong focus on changing emotions, thoughts and behaviours as invalidating. However, when she tried a therapy that focused too much on acceptance, the clients felt their suffering wasn’t taken seriously enough. She realised that accepting patients as they are and simultaneously pushing for change needed to be in balance. For that she integrated dialectical philosophy into the therapy.

Linehan saw that her clients lacked skills that could help them regulate their emotions in a constructive way. However, in the individual therapy sessions dealing with current life crises and suicidality took up so much time that they couldn’t sufficiently focus on learning and practicing new skills. To tackle that, she formed separate skills training groups where personal crises are not to be discussed in depth and a very structured protocol is to be followed.

The approach proved to be successful and in 1993, the first treatment manual was published. Since then, DBT has become increasingly popular around the world. It has become a standard of treatment for Borderline Personality Disorder (BPD) and has been adapted to treat many other disorders.

Description

There are 4 main treatment modes in DBT.

  1. The aim of individual therapy is to tackle suicidality, behaviours that interfere with therapy (e.g not attending sessions, not completing homework) and improving the client’s quality of life.

  2. In group skills training patients learn and practice new skills (Figure 1). Some skills (mindfulness and distress tolerance) are more about acceptance, some skills (emotion regulation and interpersonal effectiveness) help clients move towards change.

  3. Therapists work as a team that offers support to prevent burnout and helps therapists to keep working in accordance with the principles of DBT.

  4. When patients have trouble using their skills in everyday life, phone coaching is available.

The three main concepts that DBT is based upon are behavioural therapy (change), mindfulness (acceptance) and, for balance between the two, dialectical philosophy.

An essential idea of dialectics is that each thesis or position contains within it its antithesis or opposite position and progress comes from the resolution of these opposing positions into a synthesis. For example, a patient may wish to die and live at the same time. A resolution to this dilemma could be to build a life worth living.

In DBT an effort is made to validate the clients’ thoughts and feelings with the aim that they will eventually learn to validate themselves. This technique also helps clients analyse their behaviour and work on using new skills without feeling criticised by the therapist. At the same time, with shaping or “cheerleading” techniques, patients are praised for each step they take towards change.

<p>Figure 1: The 4 main skill sets of DBT.</p>

Figure 1: The 4 main skill sets of DBT.

Indications

For the following conditions standard or adapted versions of DBT have been found to be effective in at least one randomized controlled trial (RCT):

  • Borderline personality disorder

  • 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 personality disorder(s)

  • Bipolar disorder

  • Transdiagnostic emotion dysregulation

  • Suicidal and self-harming adolescents

  • Pre-adolescent children with severe emotional and behavioral dysregulation

  • Binge eating disorder

  • Bulimia nervosa

Efficacy

Meta-analyses have found that DBT is more effective than treatment as usual in reducing suicide attempts, non-suicidal self-injury, and anger, and improving general functioning among people with borderline personality disorder (Stoffers et al., 2012; Kliem et al., 2010). DBT has also been adapted for use for other psychiatric disorders (listed above). A comprehensive list of published evidence and regular research updates can be found here: https://behavioraltech.org/research/evidence/.

Quote from the founder:

“The bottom line is that if you are in hell, the only way out is to go through a period of sustained misery. Misery is, of course, much better than hell, but it is painful nonetheless. By refusing to accept the misery that it takes to climb out of hell, you end up falling back into hell repeatedly, only to have to start over and over again.”
― Marsha M. Linehan on the process of recovering from BPD through DBT

Comment from a trainee with personal experience:

I attended my first three-day course on Dialectical Behaviour Therapy (DBT) a few years ago, eager to understand the reasons for the sensation around DBT. I did find an evidence-based treatment that had a comprehensive theoretical background, good results and practitioners happy to evaluate their practice. I have since used the basic principles of DBT in my work with patients who suffer from emotional dysregulation and act in impulsive and self-destructive ways. I have referred many more for DBT group/individual therapy. DBT may not be a panacea but it is a very useful tool for therapists who work with a very challenging population.

- Dr Foteini Papouli

Resources

Comprehensive guidebooks:

Linehan (1993). Cognitive-behavioral treatment of borderline personality disorder.
Linehan (2015). DBT Skills Training Manual (2nd ed.).

- If working with adolescents and families:

Miller, Rathus, Linehan (2006). Dialectical Behavior Therapy with Suicidal Adolescents.
Rathus, Miller (2015). DBT Skills Manual for Adolescents.

For a more compact overview of the principles of DBT:
Van Dijk (2013). DBT Made Simple

The recommended reading list of the Linehan Institute:
https://behavioraltech.org/wp-content/uploads/2015/09/2016.RecommendedReading.Short-LIformat.pdf

Behavioural Tech (USA), a training company that also offers online courses

https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/

Germany: https://www.dachverband-dbt.de/

Austria: http://oedbt.at/

UK and Ireland: https://www.sfdbt.org/#, https://www.dbt-training.co.uk/

Netherlands and Belgium: https://www.dialexisadvies.nl/

Sweden and Denmark: https://dbt-scandinavia.se/

Norway: http://dbt.no/

Italy: http://www.sidbt.it/dbt/

Spain: http://asociacionespanoladedbt.com/

References

  • Linehan (2015). DBT Skills Training Manual (2nd ed.).

  • Van Dijk (2013). DBT Made Simple

  • Stoffers-Winterling, J. M., Völlm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K. (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd005652.pub2

  • Kliem, S., Kröger, C., & Kosfelder, J. (2010). Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling. Journal of Consulting and Clinical Psychology, 78(6), 936-951. doi:10.1037/a0021015

  • https://behavioraltech.org/research/how-dbt-helps/#Conditions. (visited 26.02.19, 20:00)

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