Dialectical Behavior Therapy: An overview on this type of therapy

Imagine having emotions that are constantly difficult to control… behaviors that are hard to live with. In this article, we will cover what dialectical behavior therapy is, what it’s used for, what it’s based on, its four modules, how it helps those with a borderline personality disorder, how it differs from cognitive behavior therapy, its effectiveness, and its flaws.

Dialectical behavior therapy

Dialectical behavior therapy

What is dialectical behavior therapy?

Dialectical behavior therapy (DBT) is a form of cognitive behavioral treatment that is meant to provide a person with new skills in order to manage painful emotions while decreasing conflict in relationships. It’s thought that this type of therapy has the capability to help those who wish to improve their ability in regulating their emotions, tolerating stress and negative emotions, being more mindful and present, and communicating effectively with others. It was developed by Dr. Marsha Linehan at the University of Washington in the early 1990’s.


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The word dialectal means to weigh and figure out contradictory facts and ideas to resolve apparent contradictions – essentially the integration and combination of opposites. It comes from the idea of bringing together two types of therapy – acceptance and change – and bettering one’s therapeutic results from combining them rather than having one, either acceptance or change, alone.

Uses of dialectical behavior therapy 

Originally used to treat borderline personality disorder, science has shown that it’s also helpful in treating people who experience depression, bipolar disorder, eating disorders, personality disorders,  post-traumatic stress disorder (PTSD), and substance abuse.

What does dialectical behavior therapy consist of?

DBT consists of three major components in treatment and methods: support oriented, collaborative, and cognitive-based.

Support-oriented methods help a person identify and recognize their strengths and helps build on them. This way, the person gains self-confidence and feels better about themselves and their life.

Collaborative methods require constant attention between the person and the therapist. Working with the therapist as much as the therapist works with you is the goal. Through the use of daily or weekly homework assignments, practicing skills like soothing when you’re upset, or role-playing new ways to interact with others, the person learns, with the collaborative help of their therapist, to apply and master the skills in order to better coping and social skills.

Cognitive-based methods help a person identify thoughts, assumptions, and beliefs that make life more difficult. For example, if someone thinks, “I have to be perfect at everything I do,”  the therapist will help them learn different ways of thinking to make life more bearable. An example is reframing thinking to the belief that “I don’t need to be perfect for people to love me.”

Dialectical behavior therapy

Dialectical behavior therapy

The 4 modules of the dialectical behavior therapy

Dialectical behavior therapy specifically focuses its therapeutic skills in four areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

1. Mindfulness focuses on improving acceptance and being (aware) at the current moment.  In mindfulness, there are two aspects: the “what?” and the “how? The “what?” skills come from observing, describing, and participating in order to answer, “What do I do to practice mindfulness?” The “how?” comes from not being judgmental, being one mind, effectiveness in order to answer, “how do I practice mindfulness skills?”

2. Distress tolerance focuses on increasing a person’s tolerance of negative emotions, rather than trying to escape from negative emotions. Essentially, tolerating pain in difficult situations, not changing it. There are four types of distress tolerance taught in DBT: self-soothing, distracting, thinking of pros and cons, and improving the moment.

3. Emotion regulation works on strategies to be able to manage and change strong emotions that are causing issues in the person’s life. Emotional regulation teaches:

  • Taking opposite action
  • Reducing vulnerability to an emotional mind
  • Learning how to properly identify and label emotions
  • Identifying obstacles to changing emotions
  • Increasing mindfulness to current emotions
  • Applying distress tolerance techniques
  • Increasing positive emotional events

4. Interpersonal effectiveness works on techniques that help the person be able to communicate assertively with people, maintaining self-respect, and strengthening relationships. Essentially it is learning how to ask for what you want and being able to say “no” while maintaining respect. People who suffer from borderline personality disorder typically have good interpersonal skills. Where they experience problems, however, is in the application of these skills in specific situations – especially when the situation is emotional or volatile.

Dialectical behavior therapy and borderline personality disorder

Dialectical behavior therapy was invented by Dr. Marsha Linehan, specifically for those with a borderline personality disorder and continues to be one of today’s leading treatment plans. Dr. Linehan hypothesized that borderline personality disorder is a consequence of an emotionally defenseless person growing up within a particular set of environmental circumstances that are referred to as an invalidating environment. In this situation, one feels constantly invalidated. An emotionally defenseless and vulnerable person has an autonomic nervous system that reacts too much to low-stress levels and takes longer than normal to return to normal once the stress is removed. In theory, this is because of a consequence of biological diathesis.

Due to a child’s invalidation in their environment growing up, they will not have the opportunity to label or understand their feelings nor will they learn how to trust their own responses to certain events. The child won’t have learned how to cope with difficult situations that could be seen as stressful or difficult since such problems weren’t acknowledged by parents. Thus, the child looks for others to validate them and help solve their problems. However, this behavior creates bad behavioral patterns and worse coping behavior. An example is failing to not only understand emotions but also failing to control emotions.

However, this is where dialectical behavior comes in – it teaches someone, who may not even know they feel invalidated, how to cope with situations that are difficult for them and that they don’t know how to handle. Dialectical behavior therapy helps a person who has little or no control over their emotions actually take control of their emotions and consequent behaviors.

Dialectical behavior therapy

Dialectical behavior therapy

Difference between cognitive behavioral therapy and dialectical behavioral therapy

Dialectical behavior therapy is a modification of cognitive behavior therapy. When DBT was first developed, standard cognitive behavior therapy techniques were used.  Some are skills training, behavior rating scales, homework assignments, and behavioral analysis to address the person’s problems. However, this didn’t work for everyone. However, some people felt that the degree of their suffering was underestimated and their therapists overestimated how helpful they were actually being. As a consequence of this, a number of people dropped out of the treatment program, having become frustrated and shut down. After this, the researchers noticed, after looking at the videotapes that were recorded of each session, some strategies worked well to help people tolerate their pain and create a “life worth living.” Acceptance strategies were added to the list of strategies used in dialectical behavior therapy and people began to feel that their therapists understood them better. In dialectical behavior therapy, there are strategies that are specifically dialectical – meaning balancing contradictory facts and ideas to resolve problems and contradictions.

Unlike cognitive behavior therapy, dialectical behavior therapy implements mindfulness, tolerance distress, and acceptance. Some cognitive behavioral therapists like to incorporate certain elements of dialectical behavior therapy. Nowadays, there are also forms of cognitive behavior therapy that incorporate some aspects of dialectical behavior therapy, for example, using mindfulness to treat depression.

Tools and techniques of the dialectical behavior therapy

Using the 4 modules for skills training. This teaches behavioral skills and is frequently taught in groups where homework can be assigned. The homework may consist of people putting into practice the dialectical behavior therapy skills they learned in class to their everyday life. It could also mean filling out a daily diary card in order to track over 40 emotions, behaviors, urges, and skills – like lying and self-respect. It takes about 24 weeks to completely get through a full skills curriculum.

Enhancing motivation with individual therapy. Individual therapies help the person apply the DBT skills they have learned to specific situations and challenges in their life. Normally, individual therapy takes place once a week and runs alongside the dialectical behavior therapy skills training.

Coaching is a form that involves using telephone coaching and another live coaching to provide real life, in-the-moment support. The goal is to help the person use their dialectical behavior therapy skills effectively in order to cope with hard situations that happen in everyday life.

Case management strategies involve helping the person manage their own lives in their normal physical and social environments. The therapist uses the same strategies in order to teach the person how to be their own “case manager,” This helps the therapist consult the patient about what to do and the therapist only intervenes when necessary.

Consultation team with support therapists help those who provide dialectical behavior therapy, like individual therapists and case managers, treat the person. Their goal is to essentially provide therapy for the therapist and be a back-up by helping the therapists stay motivated and as competent as possible to be able to do the best work possible. A consultation team is most important when there is someone with a severe, difficult-to-treat disorder that can cause the therapist to feel burnt out.

The efficiency of the dialectical behavior therapy

Dialectical behavior therapy works well because it treats the problematic behaviors that were developed in order to cope with and give temporary relief to a situation. DBT enhances and betters a person’s abilities and capabilities by teaching behavior skills that work and provide relief in both the long run and the short-term.

The first trial of dialectical behavior therapy was issued in 1991 in which the researchers found that dialectical behavior therapy provides significant improvements for chronically suicidal and self-injuring women with a borderline personality disorder. Prior to the study, this population of women was seen as untreatable.

Dialectical Behavior Therapy

Dialectical Behavior Therapy

Criticism of the dialectical behavior therapy

Nothing is perfect. Here are some downsides to dialectical behavior therapy:

  • A huge part of dialectical behavior therapy being successful for someone is that they must first acknowledge that they have a borderline personality disorder; that they want to learn about it, and want to work hard in therapy. If they don’t first acknowledge it, there isn’t much someone else can do to fix it. People who have a combined narcissistic personality disorder and borderline personality disorder, often don’t acknowledge that they have a borderline personality disorder, which makes it incredibly difficult to treat.
  • These types of therapies can be incredibly costly and are not available in all locations.
  • DBT is demanding; there are daily forms and homework to fill out, hours of therapy each week, and constant motivation.
  • Although studies have shown that dialectical behavior therapy lowers the number of suicidal thoughts and reduces the instances of self-harm, there are no studies that show that it relieves depression or makes a person happier. However, some individuals claim that it does.

Have you or anyone you know tried DBT? How did it go? Let us know in the comments!

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