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Answers to Frequently Asked Questions
about Dialectical Behavior Therapy
WHAT IS DIALECTICAL BEHAVIOR THERAPY?
DBT is a method of cognitive behavioral therapy that treats people with Borderline Personality Disorder (BPD) developed by Marsha Linehan, PhD. at the University of Washington. In DBT, behavioral change is balanced by acceptance, compassion and validation.
STRATEGIES BALANCING ACCEPTANCE and CHANGE FORM THE “Dialectic” IN DBT
Dr. Linehan studied women who met criteria for BPD – angry women, suicidal women, and drug abusing women. She found that these clients felt that their ability to change was being over-estimated while the degree of their suffering was being underestimated. She formulated strategies to help them tolerate their pain while working towards making a “life worth living”. They were taught various skills that helped them to tolerate their distress without resorting to self-destructive behaviors.
“DBT IS A LIFE ENHANCEMENT PROGRAM, NOT A SUICIDE PREVENTION PROGRAM.” LINEHAN
DBT is the only psychosocial outpatient treatment for BPD that has evidence from randomly controlled clinical trials demonstrating its success.
What is Personality Disorder?
Personality Disorders (PD) are enduring patterns of inner experience and behavior that are pervasive, extreme, inflexible and maladaptive, have on onset in early adulthood or adolescence, are stable over time, and lead to distress and impairment. A person with a PD is unable to deal with people or problems constructively or to adapt to the changing demands of the environment.
What is Borderline Personality Disorder?
BPD is an “enduring pattern” of emotional instability (moods that change quickly and unpredictably), impulsive behaviors (using drugs and alcohol, addictive behaviors, overspending, driving recklessly, eating disorders,) interpersonal instability (having trouble sustaining close relationships, chronic uncertainty about life goals,) and a propensity to self-injure, threaten or attempt suicide in an effort to solve problems. People with BPD experience emotions intensely and are very vulnerable. They are among the most intensive and extensive utilizers of mental health services. BPD is extremely painful to the patients, to those who love them and is costly to all of society.
BPD BEHAVIORS MAY BE MALADAPTIVE METHODS OF COPING WITH CONSTANT EMOTIONAL PAIN OR AN ATTEMPT TO DEAL WITH OUT OF CONTROL EMOTIONS.
DBT ASSUMPTIONS
• People with BPD are doing the best they can.
• People with BPD want to improve.
• People with BPD need to do better, to work harder, and be motivated to change.
• The lives of suicidal BPD individuals are unbearable as they are currently being lived.
• People with BPD must learn new Behaviors. for all aspects of their lives.
• People cannot fail in DBT. A DBT therapist can fail them – but DBT would suggest that there is help somewhere that must be sought
• Therapists treating people with BPD need support
• Families coping with people with BPD need support.
• Stress related dissociative symptoms such as paranoia; feeling as though they are losing touch with reality; feeling victimized; unable to accept responsibility.
• BPD is extremely painful to the patients, to those who live with them and to society. People with BPD experience emotions intensely and are very vulnerable. They are among the most intensive and extensive utilizers of mental health services.
KEYS TO A LIFE WORTH LIVING
• Supportive relationships that will nurture you
• Meaningful work
HOW IS DBT PRACTICED?
DBT is generally practiced as an outpatient treatment. Researched DBT with data to support its use includes:
1. Once weekly individual psychotherapy.
2. Two hour weekly psychoeducation skills groups.
3. Consultation meeting for therapists.
4. Therapist available for phone coaching.
Ancillary Treatment
Pharmacotherapy, acute, inpatient psychiatric treatment, day treatment, case management, and family psychoeducation.
REMEMBER, DBT IS NOT JUST SKILLS TRAINING.
A program or person who says they do DBT but only offers skills groups is not doing the comprehensive type of DBT that is effective.
CHARACTERISTICS OF DBT
DBT is Supportive: It helps a person identify their strengths and builds on them so that the person can feel better about him/herself and their life.
DBT is Cognitive: DBT helps identify thoughts, beliefs, and assumptions that make life harder: “I have to be perfect at everything.” “If I get angry, I’m a terrible person” & helps people to learn different ways of thinking that will make life more bearable: “I don’t need to be perfect at things for people to care about me”, “Everyone gets angry, it’s a normal emotion.
DBT is Collaborative: It requires constant attention to relationships between clients and staff. In DBT people are encouraged to work out problems in their relationships with their therapist and the therapists to do the same with them. DBT asks people to complete homework assignments, to role-play new ways of interacting with others, and to practice skills such as soothing yourself when upset. These skills, a crucial part of DBT, are taught in weekly lectures, reviewed in weekly homework groups, and referred to in nearly every group. The individual therapist helps the person to learn, apply and master the DBT skills.
EXPLANATION OF DBT TERMS
Behavior Therapy: The aim of “Behavior Therapy” is to help people try new ways of thinking, feeling, speaking, coping and doing things. Rather than focusing on the past, it looks at the present situation. It does not depend on the insightful discussions characteristic of psychotherapy to solve problems, although this can be valuable in its own right. It focuses on a person’s views and beliefs about their life, not on their personality traits. It aims to replace maladaptive methods of coping with more effective ways of achieving specific changes and goals, it helps a person to get what they want or need while helping them develop control of their life.
Dialectics: DBT is based on the idea that opposites can coexist and be integrated. Thinking dialectically means recognizing that both points of view in any situation are valid and means constantly working on balancing change and acceptance.
DBT TREATMENT TARGETS
Pre-treatment Targets
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Orienting and Agreement on Goal
1st Stage Targets
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Decreasing or eliminating life-threatening behaviors (suicide attempts, suicidal thinking, self-injury, homicidal and aggressive behaviors)
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Decreasing or eliminating therapy-interfering behaviors (missing sessions, not doing homework, behaving so that others burn out”. using hospitalization as a way handling crisis. ).
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Reducing or eliminating hospitalization as a way handling crisis.
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Decreasing Quality of life interfering behaviors (eating disorders, not going to work or school, addiction, chronic unemployment).
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Increasing behaviors that will enable the person to have a life worth living.
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Increasing behavioral skills that help to build relationships, manage emotions and deal effectively with various life problems. These skills are: Mindfulness, Interpersonal Relationships, Emotion Regulation, Distress Tolerance, and Self-Management.
2nd Stage Targets
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Decreasing Post Traumatic Stress Disorder
3rd STAGE Targets
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Increasing respect for self
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Setting individual goals
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Solving ordinary life problems
4th STAGE Targets
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Capacity for Freedom and Joy. Although these priorities are presented in order of Importance however
DBT practitioners believe they are all interconnected. If a person does not stay alive, they will not have the chance to receive help. If they don’t stay in therapy, they won’t get the help they need to change their quality of life. DBT aims to convince people to stay alive, stay in therapy and build a life worth living. As the person makes a commitment to life and to stopping self-destructive behaviors, DBT provides them with support in learning how to create and keep a life that is sustaining.