Dialectical Behaviour Therapy (DBT) is a therapeutic methodology developed by Linehan, a psychology researcher at the University of Washington to treat people with Borderline Personality Disorder (BPD). DBT combines Cognitive Behavioural Therapy with concepts of methodologies from various practices including Eastern mindfulness techniques. Research has shown that DBT is the first therapy that has been effective for treating BPD. Further research has been carried out and appears to show that it is also effective in treating people with spectrum mood disorders including self harming behaviour. Linehan created DBT after realising that other therapies were ineffectual when used for BPD. She recognised that the chronically suicidal people that she worked with had been brought up in invalidating environments and required unconditional acceptance in order for them to develop a successful therapeutic relationship. She also maintained that people need to recognise and accept their low level of emotional functioning and be ready to make a change in their lives.

Helping the person with Borderline Personality Disorder to make therapeutic changes in their lives is extraordinarily difficult for at least two reasons. Firstly, focusing on patient change, either of motivation or by teaching new behavioural skill, is often experienced as invalidating by traumatised individuals and can precipitate withdrawal, non compliance, and drop out from treatment on the one hand, or anger, aggression, and attack, on the other. Secondly, ignoring the need for the patient to change (and thereby, not promoting much needed change) is also experienced as invalidating. Such a stance does not take the very real problems and negative consequences of patient behaviour seriously and can, in turn, precipitate panic, hopelessness and suicidal ideation.  

DBT involves two components:

1. An individual component in which the therapist and patient discuss issues that come up during the week, recorded on diary cards, and follow a treatment target hierarchy. These sessions typically last for 45-60 minutes and are held weekly. Self Harming and Suicidal behaviours take first priority, followed by therapy interfering behaviours. After this there are issues surrounding quality of life and working towards improving one’s life in general. During the individual therapy, both the therapist and the patient work towards improving skill use to survive and manage difficult feelings. The whole session should be working towards a setting that is validating for the patient. A lot of attention should be paid to the immediate problems, feelings and actions. Often, a skills group is discussed and obstacles to acting skillfully are addressed.

2. The group, which usually will meet once a week for two to two-and-a-half hours, once a week, learns to use specific skills which can be broken down into four modules: Core Mindfulness Skills, Interpersonal Effectiveness Skills, Emotion Regulation Skills, and Distress Tolerance Skills. The room should be arranged like a classroom with the trainers (usually two) placed at the front. Issues and emotions are discussed and dealt with if they are life threatening or interfering with the group therapy. For example if someone is behaving badly this would only be addressed if it was causing a problem with the running of the group. Otherwise, it would be ignored. Skills Training is run around a manual that gives details of the programme that has to be followed. This gives guidance and advice about how it should be taught. It also contains handouts for individuals. Group work can include role-play and, as in CBT, homework is encouraged.  

Commitment Before DBT can begin, the patients have to make a commitment to participate in the therapy. This is an exercise in itself and may take several meetings. Both the patient and the therapist make explicit commitments. In practice, the therapist may initially ‘play hard to get’ and lead the patient, to persuade him or her that the programme is indeed justified.

People with BPD have often experienced treatments that have been at best unrewarding. Consequent wariness needs to be validated and the new therapeutic endeavour presented in a realistic way as promising but also demanding. Time spent on commitment before therapy is a good investment. Likewise, if the therapeutic relationship becomes wobbly or threatens to break down, then time needs to be spent on maintaining this commitment. It is usual for there to be an agreement that if three consecutive sessions of one kind are missed for any reason then the patient is out of the DBT programme.

Common Commitments in DBT

Patient Agreements

o Agree a time limit to stay in Therapy
o Work towards reducing suicidal behaviours
o Attend all Therapy sessions
o Participate in Skills Training

Therapist Agreements

o Make an effort to conduct competent Therapy
o To be ethical and professional as per professional guidelines
o To maintain confidentiality
o Obtain consent when necessary
o Be available for Therapy sessions and back up when needed

  None of these components are used by themselves. The individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behaviour in a social context.

The Four Modules

Mindfulness

Mindfulness is one of the core concepts behind DBT. It is the capacity to pay attention, in a non-judgmental way, to the present moment. Mindfulness is all about living in the moment, experiencing one’s emotions and senses fully, yet with perspective. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT Orange County does not involve any religious concepts.

Interpersonal Effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one may need, learning to say no, and coping with interpersonal conflict. Individuals with Borderline Personality Disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to a specific situation. An individual may be able to describe effective behavioural sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioural sequence when analysing his or her own situation. The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximise the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.   Emotion Regulation

Individuals with Borderline Personality Disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients may benefit from help in learning to regulate their emotions. Dialectical Behaviour Therapy skills for emotion regulation include:

o Identifying and labeling emotions

o Identifying obstacles to changing emotions

o Reducing vulnerability to emotion mind

o Increasing positive emotional events

o Increasing mindfulness to current emotions

o Taking opposite action

o Applying distress tolerance techniques  

Distress Tolerance

Many current approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasises learning to bear pain skillfully.

Distress tolerance skills constitute a natural development from mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although this is a nonjudgmental stance, this does not mean that it is one of approval or resignation. The goal is to become capable of calmly recognising negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.

Skills for acceptance include radical acceptance, turning the mind toward acceptance, and distinguishing between “willingness” (acting skillfully, from a realistic understanding of the present situation) and “willfulness” (trying to impose one’s will regardless of reality). Participants also learn four crisis survival skills, to help deal with immediate emotional responses that may seem overwhelming: distracting one-self, self-soothing, improving the moment, and thinking of pros and cons.