Dialectic Behavior Therapy is a broad-based cognitive-behavioral model of treatment developed by Marsha Linehan, Ph.D. Although initially designed to treat chronically suicidal and high-risk patients who struggle with patterns of behavior characteristic of Borderline Personality Disorder (BPD), current research shows the effectiveness of the model with other populations such as Post-Traumatic Stress Disorder, Eating Disorders, Substance Dependence, and Depression – all of which involve problems of emotion regulation. Dr. Linehan has often remarked that much of DBT is not new at all. She simply brought together very basic, well-documented behavioral strategies: contingency management, exposure treatment, cognitive modification, and skills training to create a strong behavioral treatment model. She then made it more palatable to both client and therapist by embedding it within Eastern philosophic principles that encourage the development of dialectical thinking and psychological flexibility. According to Linehan, change can only occur in the context of acceptance of what is and “acceptance of what is” is itself change.”
Essential to the practice of and appreciation of DBT is an understanding of the biosocial theory of BPD and, by extension, the general problems of emotion regulation. Disorders that are suited to DBT are essentially defined by problems in regulating emotion due to a combination of biological disposition, environmental context, and the mix between the two during development. There is a continuous and mutual interaction that occurs between a vulnerable individual and a more or less invalidating environment over time that may lead to maladaptive or inadequate emotion modulation strategies and the behavioral and cognitive dysregulation that tends to follow. This theory not only provides a base for effective intervention, it fosters a compassionate attitude toward the intensity of emotion and the difficulty of changing ingrained patterns of behavior.
DBT in its comprehensive form is a very structured approach that involves four components: DBT individual therapy, DBT Skills Training, DBT phone coaching, and DBT therapist consultation team. Although there is some evidence that skills training alone can be helpful, comprehensive DBT requires that all four components are present. The clients who are appropriately referred to DBT programs are those with multiple concurrent problems who often exhibit suicidal and other high-risk behaviors. Phone coaching between sessions is essential – you don’t send the team out on the floor for the championship game without a coach to guide plays. Coaching calls are intended to be brief interactions that help clients identify and use skills to get them through the moment. Team meetings are essentially therapy for the therapist to enable her to stay motivated and provide the best treatment possible. Despite all the structure, DBT is a not a manualized treatment. The therapist is guided by principles at every juncture to work with the client to establish treatment priorities, to build a strong, collaborative relationship, to select specific strategies to solve specific problems, to assign homework, and to clarify and maintain his/her own limits with firmness, compassion and flexibility.
Further information about DBT resources, training, and research can be found at behavioraltech.org
Debora B. Dixon, Ph.D.
20 York Street, Bath, ME 04530