Dialectical Behaviour Therapy (DBT) integrates aspects of Cognitive Behavioural Therapy (CBT) techniques with Eastern and Zen practices including Mindfulness, and is the leading therapy for the treatment of Borderline Personality Disorder (BPD)
Within every unwise act, there is some inherent wisdom
Chances are, if you take a trip to your local High Street bookshop and check out the Psychology or Therapy section, you'll find just a couple of books on Cognitive Behavioural Therapy ('Teach Yourself…', or '…for Dummies', or mabye something similar). Perhaps you'll come across an Encyclopedia or Dictionary of Psychology/Psychiatry, and possibly one or two other, miscellaneous 'primers'.
But flick through to the index in any one of these books and check under 'D' for information about Dialectical Behaviour Therapy, and it's doubtful you'll find anything at all about this treatment.
Dialectical Behaviour Therapy, or DBT, is so 'under the radar' of conventional mental healthcare that, simply by reading this article, you've joined a rather exclusive club.
And with good reason. DBT was designed to treat those who've been diagnosed with Borderline Personality Disorder (BPD), and while demand for DBT is high, counsellors and therapists have been known to seek to avoid such patients.
When it comes to Borderline Personality Disorder, Cogntive Behavioural Therapy, the treatment of choice for many emotional disorders, can get you only so far, as Borderline Personality Disorder is considered one of the most difficult psychological problems to treat.
In fact, there comes a point when treating a Borderline patient with CBT can actually become counter-productive.
The first, most obvious and burning question asked, whenever someone first discovers and wants to understand more about Dialectical Behaviour Therapy is 'what's the "dialectical"?'Dialectical Behaviour Therapy - Radical Acceptance
Essentially, "dialectical" refers to the approach of the therapy. It's about balancing both change and acceptance strategies. Acceptance is change! Change only happens in the context of acceptance.
Although not normally applied to psychotherapy, the concept of 'dialectical' is fairly well known in the fields of history, economics and science. The concept has three primary characteristics:
- it stresses the interrelatedness and wholeness of reality. The whole is more than the sum of its parts
- reality is seen as composed of two opposing forces (thesis and antithesis), out of whose synthesis evolves a new set of opposing forces. In terms of therapy, it means the objective of the therapist is to help the patient move towards a more balanced, synthesised response
- reality is seen as in a context of a continual process of change. Part of the role of the therapist is to find ways for the patient to become comfortable with ambiguity and change
In the dialectical perspective, everything is pregnant with its opposite, and with a ready eager eye one can discern the potential for change even when it seems nothing is changeable
In her superb The Buddha and the Borderline (2010), Kiera Van Gelder, a Borderline survivor, gives the perfect introduction to the concept of the dialectic as it relates to boderlines:
[Borderlines] can't tolerate criticism. For us, therapy's constant emphasis on 'fixing ourselves' and the pressure to change is like pushing someone whose back is already against a wall — a wall full of spikes. When the focus is solely on change, we tend to flee therapy or stay very angry and defensive. On the other hand, too much unconditional acceptance by the therapist can keep us stuck. In either case, we often get worse.
On the most practical level, then, dialectical is the fusing together, or synthesising, of two opposites, to create something new. DBT is an approach which focuses on changing problematic thoughts, feelings and actions (in a way which will be familiar to those who have experienced CBT), and at the same time encompasses a more compassionate, non-judgmental and Mindful approach, rooted to some extent in the practice of Zen Buddhism.
Synthesising change and acceptance, two completely contradictory techniques, is at the core of the dialectical nature of Dialectical Behaviour Therapy.
Marsha Linehan has used the descriptive tool of an image of a "teeter-totter", or see-saw, with therapist and patient at opposite ends, and the therapy, Dialectical Behaviour Therapy, seen as the process of moving back and forth, sliding up and down, both trying to balance it so that they can each move towards the middle together. Once there, there is another see-saw, at a higher level, where the process begins again, then another, and so forth - the higher level see-saw represents growth and development — a synthesis.
When it comes to helping suicidal patients, Linehan replaces the see-saw with an altogether more formidable metaphor: patient and client here are balanced on a bamboo pole, perched precariously on a high wire, stretched over the Grand Canyon.
Thus when the patient moves backwards on the pole, if I move backward to gain balance, and then the patient moves backward again…we are in danger of falling into the canyon
DBT: The beginning
DBT actually started as a research project which Marsha Linehan, a Behavioural Therapist, was conducting in order to show how successful Behavioural Therapy could be with suicidal patients. It's a form of cognitive-behavioural therapy but one that's developed specifcally as a comprehensive treatment for chronically suicidal individuals who meet the criteria for Borderline Personality Disorder.
The idea is two-fold: (1) borderline individuals lack important interpersonal, emotion regulation and distress tolerance skills, and (2) personal and environmental factors inhibit the use of whatever behavioural skills the borderline individual actually does possess.
DBT is based on a biosocial interpretation or theory of Borderline Personality Disorder and, in particular, its core dysfunction, "emotion dysregulation".
In this view, extreme vulnerability, oversensitivity and problems associated with 'returning to baseline levels' are seen as the result of the interplay between biological mechanisms (such as trauma to the nervous system) and genetic influences, on the one hand, and social/environmental factors, often described as an "invalidating environment" (negated, trivialised or ignored emotions, etc.), on the other.
DBT conceptualises BPD in terms of three dialectical dimensions:
Biological (emotional vulnerability; active passivity; unrelenting crises Environmental
emotional vulnerability versus invalidation
versus apparent competence
unrelenting crises versus inhibited grieving
Borderlines, then, are seen as vacillating between the polarities of each dimension
And the objective of Dialectical Behaviour Therapy, therefore, is to move Borderline sufferers away from these extremes — a balanced synthesis.
So, DBT is a form of Cognitive Behavioural Therapy?
Certainly, DBT emphasises behavioural assessment (of current behaviours), is target-driven, psycho-educational and stresses a collaborative relationship between Therapist and Patient. And at the heart of DBT you will find exposure techniques, skills training, contingency management and cognitive modification.
But there are differences to CBT as well:
1. Dialectical Strategies
An emphasis on dialectics permeates throughout, as you'd expect. The primary strategy is that of combining acceptance with change. The therapist tries to show that for every point there is an opposite position that can be held, which helps the patient to create a new, synthesised reality.
The therapist uses, story, metaphor, myth, ambiguity and paradox to draw out the fact of reality as constant change (including non-avoidance of change); cognitive challenging/restructuring; and reinforcement of intuitive, non-rational knowledge.
2. Acceptance-Change focus
When it comes to DBT, acceptance is a radical notion. It doesn't just mean "acceptance in order to create change", but refers to genuine acceptance of all reality, as it is in the current moment. Acceptance means experiencing without rejecting the experience of that moment. Clarity without clinging, or pushing past, or away. It means total awareness without judgment (good or bad). Each DBT strategy can be categorised as either primarily about change, or about acceptance, and the balance of the two is the fundamental dialectical paradox.
3. Therapy Interfering Behaviours
As a DBT therapist, I'll admit to getting quite frustrated when Borderline patients frequently engage in behaviours that impede therapy progress. Therapy-interfering behaviours, of both patient and therapist are high priority targets in DBT, second only to the patient's high-risk, self-destructive behaviours.
4. The Therapeutic Relationship
A positive interpersonal therapeutic relationship is crucial to progress in therapy. The relationship is not only the vehicle through which the therapist effects change but is, itself, the therapy, particularly for suicidal or self-destructive patients. Further, the effectiveness of many of the strategies of DBT depend on the presence of a strong relationship.
How effective is Dialectical Behaviour Therapy?
DBT is one of the few psychsocial interventions for BPD that has controlled empirical evidence for its effectiveness. Results tend to show that DBT patients are less likely to attempt suicide or to drop out of therapy than treatment-as-usual (TAU) patients. The also spend less time in psychiatric hospitals and are better adjusted interpersonally and less angry.
DBT works by homing in on the specific issues that are causing distress and then teaches skills to deal with them without having to resort to self-defeating behaviours. But it does so from the standpoint that you are doing the best you can, eventhough you may need to learn ways that work better
Clients in DBT receive three main modes of treatment: individual therapy; group skills training; and phone consultation. In individual therapy, clients recieve once-weekly individual sessions that are typically an hour to an hour-and-a-half in length. Clients also attend a two-hour weekly skills group for at least a year. The groups are psychoeducational (taught in class), where four sets of important skills are learned:
- Interpersonal Effectiveness
- Emotional Regulation
- Distress Tolerance
The key goal in DBT is that of creating a "life worth living", though of course what precisely makes a life worth living can vary. For some clients it's getting married, or finding a partner, or having a family, for others it's completing their formal education and studies, getting a settled home, or finding some form of spiritual fulfillment.
But clearly, borderlines have a more pressing need to bring under control certain behaviours which threaten their existence, let alone stand in the way of creating that life worth living. For this reason, DBT organises treatment into four stages, with specific targets:
Stage 1: Moving from being out of control of one's behaviour, to being in control
Target 1: Reduce and then eliminate life-threatening behaviours (e.g. suicide attempts, suicidal thinking, intentional self-harm)
Target 2: Reduce and then eliminate behaviours that interfere with treatment (e.g. behaviour that "burns out" people who try to help, or other therapy-interfering behaviours)
Target 3: Decrease behaviours that destroy the quality of life (e.g. depression, phobias, eating disorders, absenteeism, neglect of health and hygiene, lack of money/friends, etc.) and increase behaviours that make a life worth living
Target 4: Learn skills that help control their attention, so they stop obsessing about the past or worrying about the future, increase awareness of the 'present moment' to gain an understanding of what actually makes them feel good or bad
Stage 2: Moving from being emotionally shut down to experiencing emotions fully
This stage is about helping clients experience feelings without having to shut down or dissociate, or by avoiding life, or by suffering symptoms of PostTraumatic Stress (PTSD). At this stage, clients are in control of their behaviour but are living lives of "quiet desperation". The objective is to teach the client how to experience all of his/her emotions without shutting down those emotions, even letting the emotions dominate.
Stage 3: Building an ordinary life, solving ordinary problems
In this stage, clients work on ordinary problems like marital or partner conflict, job satisfaction, career goals, etc.
Stage 4: Moving from incompleteness to completeness/connection
Very much an "existential" stage, it deals with questions of 'spiritual' lacking or emptiness. Many clients use this stage to find meaning, through spiritual and more worldly/material paths.