Dialectical Behavioral Therapy (DBT) was developed by psychologist Marsha Linehan in the 1970’s and 1980’s and published in 1993. Trained in Cognitive Behavioral Therapies (CBT), Linehan found CBT insufficient to help severely troubled clients who met diagnostic criteria for Borderline Personality Disorder (BPD), a mental health condition then considered by many psychotherapists too difficult to treat. DBT has been clinically shown to be effective in the treatment of BPD, concurrent substance abuse, and eating disorders. The principals of DBT can be helpful in general, especially for clients with serious or intractable mental health problems.
While CBT helps people become aware and change their thoughts and behaviors, DBT also helps people learn to validate their thoughts and behaviors. People with more severe problems may need to learn they are not “crazy” or “unacceptable,” but that their thoughts and behaviors make sense on many levels. DBT introduces a dialectical (“yes…and”) approach to help clients both validate themselves and work on change at the same time. A dialectical approach both helps the client understand their problematic symptoms (that it makes sense they evolved, it makes sense they keep recurring, that many others have these symptoms, and that they are deserving of compassion rather than judgment) and helps the client understand the full cost of the symptoms in terms of their life and the importance of change. Dialectical thinking more generally helps people see more than one perspective, and helps people stop warring back and forth in their mind (or with someone else) between seemingly contradictory positions. When we think dialectically, we ask “What other perspectives are there?” and find the validity in each perspective.
Another contribution of DBT is the structuring of treatment around a prioritized list of problems to be treated and stages of treatment. Because people with severe symptoms can have many problems, having a clear and logical priority and order in which symptoms are targeted for treatment can be important for progress. Different approaches are used in different stages of treatment, and close attention is paid to what stage the client is in at any given time. When the clients is feeling hopeless, overwhelmed, or otherwise reluctant to commit to the seemingly enormous amount and difficulty of work required for treatment, therapy focuses on helping the client become committed to treatment. When the client is committed, they may engage in a component of CBT.
A final way in which DBT departs from CBT is in its broader conceptualization of treatment. Treatment includes more than just individual psychotherapy sessions. Clients generally also attend weekly skills training groups in which they learn and practice skills in mindfulness (ways to be effectively aware of what’s going on in your mind), managing emotions, managing high levels of stress, and being effectively assertive. Outside of individual therapy and group skills training, clients may also be encouraged to call their therapists for coaching by phone to help them transfer skills to their daily life. Attention is paid to how the client’s home or work environment might interfere with the client’s treatment, and the client or client and therapist may meet with others to attempt to change these. Finally, DBT also includes weekly consultation meetings for therapists to develop therapist skills and motivation. Therapy is not considered to be DBT unless all these treatment components are in place.
