Earlier this month, I was excited to see Playmore & Prosper host the space for DBT Associates’ Intensive Dialectical Behavioral Therapy (DBT) Training. Since DBT has grown in popularity in recent years, it’s a term that many people in the psychological community are familiar with. Intrigued by the hype about DBT—it’s the treatment of choice for Borderline Personality Disorder—I set out to research a few questions about it. What is the history of DBT – and crucially, what IS it? What does a DBT session look like – and what evidence shows that it’s effective? (In other words, does it live up to its reputation?) These questions provided me the inspiration for this week’s blog – so if you’re wondering about these things too, stick with me.
What is the history of DBT?
DBT is a type of therapy that was founded by Dr. Marsha Linehan in the 1990s and was originally meant to be a treatment for Borderline Personality Disorder (BPD). Linehan herself has BPD: she was hospitalized at 17 after several self-harm attempts and struggled throughout her 20s with mental health concerns. After recovering and gaining a PhD in Psychology from Loyola University Chicago, Linehan developed DBT in part through her own struggle with the disorder.
BPD is characterized by extreme shifts in mood and instability in relationships. Linehan noticed how BPD patients, including herself, experienced treatment as dehumanizing. In other words, BPD patients would be treated as a collection of problems that needed to be solved instead of people. DBT addresses this negative therapeutic mindset through its emphasis on validation. Key to this concept of validation is DBT’s dialectic of acceptance and change: clients are encouraged to both accept who they are at the core and commit to change maladaptive behaviors. From being a treatment focused mainly on BPD, DBT has evolved to treat a variety of mental health disorders, including mood disorders such as depression and substance abuse disorders.
What are the core principles of DBT?
There are four “modules” of DBT that clients learn: Mindfulness, Emotion Regulation, Distress Tolerance, and Interpersonal Effectiveness. Mindfulness is considered the core module for DBT; it is based on Eastern meditation and Zen practices modified to emphasize behavioral and psychological principles. The purpose of mindfulness is to balance “reasonable mind” (cold, hard logic) with “emotional mind” (instinct and emotion) to reach “wise mind” as a synthesis of the two extremes. “Wise mind” is a dialectical balance between two opposing forces, a recognition that life can be “both…and” rather than "either…or.”
Emotion Regulation teaches skills to reduce a person’s vulnerability to negative emotions while increasing their experience of positive emotions. Emphasis is often placed on healthy living, such as getting enough sleep and exercising. Distress Tolerance focuses on how to change your emotional response to upsetting situations through acceptance, distraction, or tolerance. The last module is interpersonal effectiveness; its core principles are assertiveness, sticking to your values, and showing interest in others to build relationships. Together, the four modules of DBT address symptom reduction, improve quality of life, and enhance the ability to live in the moment.
What happens during a session of DBT?
DBT clients are required to commit to a specific amount of time in DBT to fully learn the skills; depending on the agency, the amount of time can be from 6 months to over a year.
Typically, clients are required to attend DBT in both a group setting with a DBT therapist facilitator and individually. Each group session has a small number of clients who work as a source of accountability and support for one another. The group sessions consist of skills trainings and diary cards. The skills trainings are a classroom-type lecture given by the therapist group facilitator that focus on the four modules of DBT (See: What are the core principles of DBT?). In addition, group member fills out a “diary card” over the week of their symptoms, rating their depression, anxiety, anger, and skill usage. During the group session, each client runs through their diary card and explains how they utilized DBT skills to address increases in symptoms (or how DBT decreased symptoms). There is then a brief opportunity for group members to give one another feedback on how to most effectively utilize skills.
Individual therapy sessions focus on cementing what was learned in group therapy and spending more time discussing symptoms as well as the implementation of DBT skills. These sessions are also an opportunity for clients to address topics which they may not be comfortable talking about in a group setting & receive more personalized advice about skill usage. Traditional talk therapy might also be a part of individual DBT therapy, but to a large extent the focus is on using DBT for symptom reduction. That said, DBT sessions may look different depending on where treatment is received, and many clinicians only use part of the DBT model that Linehan described in Skills training manual for treating borderline personality disorder. For example, Linehan’s model includes in-the-moment phone coaching and therapy consultation teams which may not always be utilized in practice.
What is the evidence for DBT?
Research has found that DBT is an effective method of treatment, particularly for BPD. The initial flagship study of DBT by Linehan (1991) found that BPD patients in a DBT group were less likely to perform self-harm behaviors, more likely to continue therapy, and had less frequent stays in inpatient facilities. From this foundation, extensive research has been conducted to provide evidence for DBT’s effectiveness in treating many mental health disorders. For example, DBT has long been implicated (and shown to be effective) in the treatment of binge-eating disorders (Telch, Agras, & Linehan 2001), substance abuse disorders (Linehan et. al 1999), and depression (Lynch, Morse, Mendelson, & Robins 2003). A meta-analysis conducted by Panos, Jackson, Hasan, & Panos (2013) also concluded that DBT reduces suicidal and parasuicidal (self-harm) behaviors more than a treatment-as-usual group – which has implications for the treatment of psychological disorders containing these features.
Countless other studies exist and more continue to be published on a frequent basis: check out Behavioral Tech LLC's website to get an idea of how many articles are published monthly on DBT. Summing up, the evidence base of DBT is its strength: a number of empirical studies have been successfully conducted for this type of therapy.
Hopefully, this helped clear up some of your questions about DBT – but know that this blog has only scratched the surface of DBT. Feel free to check out the references below if you want to take more of a deep-dive into DBT. Also, be aware that Playmore & Prosper will provide the space for another training by DBT Associates from June 25 to 27th. Meanwhile, stay mindful and remember that spring is almost here - those winter distress tolerance skills won't be needed much longer!
Linehan, M. (1993). Skills training for borderline personality disorder.
Linehan et al. (1991). Cognitive-behavioral Treatment of Chronically Parasuicidal Borderline Patients.
Linehan et. al (1999). Dialectical Behavior Therapy for Borderline Personality Disorder.
Lynch, T., Morse, J., Mendelson, T., & Robins, C. Dialectical Behavior Therapy for depressed older adults: a randomized pilot study.
Panos, P., Jackson, J., Hasan, O., & Panos, A. (2014). Meta-analysis and systematic review assessing the efficacy of Dialectical Behavior Therapy.
Telch, C., Agras, W., & Linehan, M. (2001). Dialectical Beahvior Therapy for Binge Eating Disorder.