What does DBT treat?
Research shows that DBT can be helpful in tackling problems like:
It was originally developed for borderline personality disorder (BPD), so most of the evidence for it so far has been about treating people with this diagnosis. Some NHS services are also starting to offer DBT for:
But regardless of your diagnosis or problems, DBT might not be right for you.
DBT is more likely to work for you if:
You’re committed to making positive changes in yourself
You’re ready to work hard at therapy, and do homework assignments
You’re ready to focus mostly on your present and future, rather than your past
You feel able to do some sessions in a group with others
Some people like group work, but others find it harder. You might ideally prefer to work with a DBT therapist 1-to-1, but unfortunately this is not always offered as an option. Talk to your doctor about what you would find most helpful to see what is available in your area.
It’s important to remember that everyone experiences therapy differently.
By Stephanie Vaughn, PsyD
This presentation is an excerpt from the online course “DBT in Practice: Mastering the Essentials”.
A primary goal for DBT individual therapists is to help motivate clients
In addition to individual therapy sessions, DBT individual therapists provide intersession contact and attend peer consultation team weekly
The relationship between therapists and clients in DBT is considered to be a “real relationship between equals,” involves mutual self-disclosure, and is collaborative
The roles and activities of a DBT therapist are many. DBT individual therapists must be well grounded in the theory and practices of DBT as a whole. They have a variety of roles including being a navigator to the process of DBT. DBT can be experienced as something foreign even to those who have been in therapy for many years and there are many facets of DBT that are new. To be a navigator in the beginning and throughout the process so that the patient doesn’t feel like they’re thrown into the deep waters of the unknown can make the difference between a patient staying in therapy and dropping out.
The DBT individual therapist must also be a motivating cheerleader. So motivating the client for change is important. Part of our role as individual therapists in DBT is to cheerlead and to remind the patient that they have access to skills and resources and that basically they can do it. Of course, we want to balance that with validating that the patient’s situation is in fact a terrible situation or that it is unbearable as it is currently being experienced. So an important role of the DBT therapist is to stay dialectic. So we do both and we want to be both centered and flexible. We want to be both nurturing and demanding. And we want to focus on accepting the patient as they are, the acceptance piece, while at the same time being oriented to change and motivating them to change.
So we’re a collaborator with the patient in the process of change. The DBT therapist believes deeply in the autonomy of the client, that the client is their own individual separate entity with their own wise mind and they have an innate right to make their own decisions in the world. As a collaborator, the DBT theory is that the relationship between the therapist and the patient is a real relationship between equals, not some sort of false alternative universe sort of relationship. It is a real relationship. Both parties find out information about one another. They see each other in a real setting, in a couch, in a couple of chairs that they develop a real relationship and DBT acknowledges that is the case. The therapist does self-disclose more in DBT perhaps than in other therapies. And part of the orientation for clients who have been in other types of therapy involves making sure that they are aware that the DBT therapist self-discloses as part of that real relationship and partly as a contingency management strategy at times.
The DBT individual therapist is also a teacher. So they must be well grounded in the skills that they teach and are continuously practicing them on their own. They need to be well versed in behavioral principles and can use behavioral language. We want to try to teach the patient to be ultimately their own therapist and to use the very skills that we learned in school and in continuing education on themselves and change their environment as is possible and radically accept when it’s not possible. So cognitive theory is also extremely important in DBT and we want to teach all those cognitive principles to our patients. So the DBT therapist also needs to be grounded in cognitive theory and any other methods of change because ultimately as we’ve referenced before DBT is a model of change and that change is what is going to be the most helpful for patients to create their life worth living. We’re teaching the practice of mindfulness. So the DBT therapist needs to practice their own mindfulness strategies and to be well versed in the principles of mindfulness and how to apply it in any given moment so having a repertoire of mindfulness activities to fall back on.
The individual therapist is really the juggler also of all of the problems their patient brings in to session. They need to be able to use the target hierarchy that we’ll be discussing in another module. And they need to be able to prioritize the time in session to utilize the diary card to determine which topics to cover first, for how long and at what intensity and all within a 45-minute or a 60-minute session getting in all of the important and essential discussions particularly those involving life-threatening behavior even when the patient is insistent that other topics take priority. So the DBT therapist is the juggler of all of the problems within a session.
They are also the validator. They need to be able to fall back to validation when the change strategies become too aversive. The individual DBT therapist needs to be able to move very quickly from change strategies to acceptance-validation strategies sometimes within a minute. They may move from change to acceptance from session to session but need to be able to have that flexibility in responding. So understanding the six levels of validation is important and to keep that label in mind, “which level am I validating at right now?” and recognizing whether validation is going to be helpful for the long-term from one moment to the next. More on validation strategies in another recording.
The DBT therapist needs to keep the overarching DBT theories in mind and let that flavor their interventions. In any given session, in any given moment, there may be a variety of and often multiple paths to take in decision making of how to respond to a patient. But all of those need to go back to some sort of DBT principle or idea. And so we are looking in DBT following the spirit of the law rather than the letter of the law at all times. And the dialectic there being of course we want to follow the letter of the law in DBT and at the same time, not but, and at the same time when those letters of the law don’t fit, we need to be able to go back to the spirit of the law and make our critical decisions based on theory and just what makes sense and wise mind.
A primary goal for DBT individual therapists is to help motivate clients. The relationship between therapist and client in DBT is considered to be a real relationship between equals, involves mutual self-disclosure and is collaborative.
More DBT In Practice: Mastering the Essentials presentations
As we noted in the above paragraphs, cognitive behavioral therapy techniques were not enough to help clients who were suicidal and chronically self-harming in the context of Borderline Personality Disorder (BPD). It’s not that the techniques were ineffective; it’s just that as stand-alone interventions, they caused clients a great deal of distress. Clients found the pushing for change invalidating. In a simple example, it’s as if therapists were saying to someone with severe burns on the soles of their feet, “just keep walking and your feet will get stronger…try not to think about the pain,” though each step was excruciatingly painful, and the patient was depressed and had no experience with keeping her mind off severe pain.
Linehan and her research team discovered that when the therapist weaved an emphasis on validation with an equal emphasis on change, clients were more likely to be collaborative and less likely to become agitated and withdrawn. So what is validation? It means a number of things. One of the things it does not mean, necessarily, is agreement. For instance, a therapist could understand that a client abuses alcohol to overcome intensive social anxiety, and yet realize that when the client is drunk, he makes impulsive decisions that may lead to self-harm. The therapist could validate that: a) her behavior makes sense as the only way she’s ever gotten her anxiety to go down; b) her parents always got drunk at parties; and c) sometimes when she’s drunk and does something impulsive, the impulsive behavior can be “fun.” In this case, the therapist can validate that the substance abuse makes sense, given the client’s history and point of view. But the therapist does not have to agree that abusing alcohol is the best approach to solving the client’s anxiety.
In DBT, there are several levels and types of validation. The most basic level is staying alert to the other person. This means being respectful to what she is saying, feeling, and doing. Other levels of validation involve helping the client regain confidence both by assuming that her behavior makes perfect sense (e.g. of course you’re angry at the store manager because he tried to overcharge you and then lied about it) and by treating the other person as an equal (i.e., as opposed to treating her like a fragile mental patient).
In DBT, just as clients are taught to use cognitive behavioral strategies, they are also taught and encouraged to use validation. In treatment and in life, it is important to know what about ourselves we can change and what about ourselves we must accept (whether short term or the long term). For that reason, acceptance and validation skills are taught in the skills modules as well.
There are four skills modules all together – two emphasize change and two emphasize acceptance. For example, it is extremely important that clients who self-harm learn to accept the experience of pain instead of turning to self-destructive behavior to solve their problems. Likewise, clients who cut themselves, binge and purge, abuse alcohol and drugs, dissociate, etc., must learn to simply “be with” reality, as painful as it may be at any given moment, in order to learn that they “can stand it.” DBT teaches a host of skills so that clients can learn to stand still instead of running away. DBT also teaches clients how to work to understand why their lives are so hard.
“Dialectics” is a complex concept that has its roots in philosophy and science. We won’t go into its background here but we will attempt to explain what we mean by dialectics and give examples of thinking dialectically. “Dialectics” involves several assumptions about the nature of reality: 1) every thing is connected to everything else; 2) change is constant and inevitable; and 3) opposites can be integrated to form a closer approximation to the truth (which is always evolving). Here’s a brief example about how these assumptions would come into play in a DBT program. Suppose you are silent in groups. The other group members are affected by your silence and they try to get you to talk. You affect them and they affect you. Perhaps the group pushes you so hard that you feel like quitting and you talk even less. Then the other members get tired of your silence and withdraw. Paradoxically, this makes you feel better and causes you to talk a bit more. As you become a true member of the group, the leaders shift the way they run the group in order to manage the tension between you and the other members. In other words, you are all interconnected, influencing each other in each moment.
As time passes in the group, there are inevitable changes. Perhaps the group becomes more skilled at getting you to talk. Perhaps you take some risks and talk more. Maybe a new member enters the group while an older member of the community transitions out and the group struggles to adjust to the new arrangement. You also may become aware that your thoughts and feelings change throughout the group, as does every other group member’s. You notice that the group is constantly evolving, constantly readjusting itself. Thinking dialectically means recognizing that all points of view—yours, the other members – have validity and yet all may also be wrong-headed at the same time. If the group is working together dialectically, the group leaders and the members are in constant flux, looking at how opposing points of view can be in play and yet be synthesized. In short, the group is always balancing change and acceptance. Throughout, the group leader and the members would try to hold on to the idea that everyone is doing the best he or she can AND that everyone has got to do better.
DBT also involves specific dialectical strategies to help clients get “unstuck” from rigid ways of thinking or viewing the world. Some of these are traditional Western therapy interventions and others draw on Eastern ways of viewing life. If you read Linehan’s (1993a) text, you can read about these strategies in chapter seven and review the examples she gives. But here are two examples. Suppose a client makes a strong initial commitment to do a year’s worth of DBT. Rather than simply saying “Hey, that’s terrific!” the therapist would gently turn the tables on the client by asking, “Are you sure you want to? It’s going to be very hard work.” This strategy, called “Devil’s advocate,” causes the client to argue in favor of why and how she will complete the therapy and not drop out. In this case, the therapist guides the client to strengthen her (the client’s) arguments for being accepted into treatment, rather than the therapist trying to convince her to stay. “Making Lemonade out of Lemons,” another strategy, also helps the clinician handle similarly tough situations. For instance, a client may complain that she absolutely hates her group therapist and wants to switch skills groups. The therapist might respond with an opposing suggestion: This can be seen as a learning opportunity in handling intense negative emotions towards authority. The therapist could then show the similarity between the client’s group therapist and other persons of authority (teachers, bosses, supervisors), and demonstrate this as a chance to tolerate a person one can’t stand but has to work with. As these examples illustrate, the point of all dialectical strategies is to provide movement, speed, and flow so that therapist and client do not become stuck in “I will not do that” vs. “Oh, yes you will!”
Linehan, M.M. (1993a). Cognitive behavioral therapy for Borderline Personality Disorder. New York: Guilford Press. This is the published treatment manual for the entire treatment. Many lay-people say this is a difficult read, though very helpful. For that reason, many start by reading the skills manual listed next.
Linehan, M. M. (1993b). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press. This manual gives an excellent overview of DBT and the skills-training in the program.
Pryor, K. (1993). Don’t Shoot the Dog! New York: Bantam Doubleday Dell Pub. This is a great introduction to principles of learning and behaviorism by a dolphin trainer. Her techniques apply to all of us.