Dialectical Behavioral Therapy is a type of talk therapy (aka psychotherapy) designed for people who experience a very intense range of emotions. It was originated by Dr Marsha Linehan when she was treating people she would later recognize to have borderline personality disorder.
Traditional talk therapy requires a patient to come in and be willing to discuss their problems while the therapist listens and asks questions. The information gleaned from these sessions would allow the therapist to root out problems and provide ideas of how to improve the situation. However, due to the sensitive nature of people with BPD, this often caused a backlash from the patient who saw the advice as being told they were the problem. Similarly, a more accepting form of therapy where a therapist would validate the patient’s experiences without offering advice wouldn’t work either as the patient felt like they weren’t receiving any help.
Instead, DBT looks to combine these two approaches – offering both validation and methods of change to the patient.
What is dialectic behavioral therapy used for?
As well as treating borderline personality disorder of all four subtypes (discouraged, impulsive, petulant and self-destructive), DBT can be used to treat a wide range of mental health conditions such as:
- Bipolar disorder.
- Depression.
- Anxiety.
- Suicidal behavior.
- Self-harm.
- Substance abuse.
- Eating disorders.
What actually is dialectical behavioral therapy?
Dialectical Behavioral Therapy consists of four core components: a skills training group, individual talk therapy, telephone consultation, and a therapist consultation team.
The skills training group is designed to help patients target negative behavioral responses that cause instability and duress and replace them with positive responses. A group will typically meet once a week for two hours with the course taking around six months to complete. patients can repeat the course or just certain modules if they feel it would be beneficial. During the course, they will be assigned homework to reinforce what they have learned and to help turn the new skills into consistent, positive habits.
Skills Training Group
The main focus during the skills training group is on mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance.
The mindfulness portion of the course teaches patients how to be present in the moment – processing what they are thinking and feeling and calmly accepting these sensations. The mindfulness skills are separated into “what” and “how” skills. The patient is taught how to observe, describe and participate fully in the moment during the “what” skills portion. What is happening around you? What emotions are you feeling? What do these emotions make you want to do? This level of mindfulness will help to reduce impulsive or emotionally charged behavior.
The “how” skills help to teach the patient not to judge themselves in a negative way for their emotional response. This helps the patient to avoid triggering negative behavioral responses.
The interpersonal skills section of the course focuses on how to socialize with others in an effective manner. People with borderline personality disorder have often suffered a form (or multiple forms) of abuse during their upbringing that have left them with poor social skills that have been built up as a defense mechanism. These poor social skills tend to lead to tumultuous relationships, which leads to more poor social skills and defense mechanisms. The patient will taught how to recognize what they need from a relationship, how to ask for it in an appropriate way, how to say “no” to inappropriate demands from others and how to cope with conflict.
People with BPD often suffer from intense and volatile emotions. The emotion regulation module of DBT therapy begins with working on identifying emotions and emotional responses so the patient can recognize how one leads to the other. Patients will learn how to identify roadblocks to changing their emotions and how best to deal with them. Patients are also taught how to avoid negative situations that lead to negative emotions and how to increase the positive situations in their lives instead.
By trying to completely avoid distress, as some people with BPD do, you are missing out on many aspects of life as well as further weakening your tolerance of distress when it inevitably occurs. The Distress tolerance module will teach patients that emotional pain and times of suffering are inevitable and should be accepted as part of life. Patients will be taught how to survive crisis situations by adjusting their thoughts, distracting themselves and self-soothing. Acceptance skills will also be taught to help patients making previously intolerable emotional pain much more bearable.
Individual Talk Therapy
Individual talk therapy is what many would consider the standard therapy experience. The patient and therapist will meet on a regular basis to discuss what’s going on in the client’s life with a focus on how it relates to their borderline personality disorder and the treatment they’re receiving. There are six main areas of focus: parasuicidal behaviors, therapy-interfering behaviors, behaviors that interfere with quality of life, behavioral skills acquisition, post-traumatic stress behaviors, and self-respect behaviors.
If a patient is feeling suicidal, this needs to be discussed and explored in detail. The therapist will help the patient develop coping and distress management techniques to help ease the burden of these thoughts and feelings. Problem-solving behaviors will also be taught to stop recurring triggers that lead to suicidal thoughts.
Therapy-interfering behaviors can be caused by both the patient and the therapist and need to be discussed openly and with as little judgment as possible. While therapy-interfering behaviors are more often demonstrated by the client, the therapist can cause issues themselves if, for example, they’re not perceived to be actively listening to the client. Other examples of therapy-interfering behaviors include: poor attendance/repeat tardiness, argumentative behavior and noncompliance.
Behaviors that interfere with quality of life include substance abuse, high-risk sexual behavior, gambling/risky investments, unemployment and anything else that might negatively impact the physical or mental health of the client.
The acquisition of positive behavioral skills is vital to help the client improve their life. These skills are taught in the skills training group and progress and ideas for improvements will be discussed during the individual talk therapy.
Many people with borderline personality disorder have suffered through one or more traumatic events during the course of their lives. It is extremely important to discuss these events when the patient feels emotionally ready to do so. This can be one of the most difficult elements of talk therapy as it involves dredging up memories that many clients would rather forget. However, a therapy can help re-frame these events and help the client reduce any blame they put on themselves and reduce intrusive thoughts caused by the event.
Last but not least, the therapist will reinforce behaviors that show the client respects themself. This includes things like being able to say no to others, talking about yourself in a positive and realistic manner, and surrounding yourself with people who treat you well.
Telephone Consultation
Telephone consultations allow the patient quick (although not necessarily immediate) access to their therapist for in-the-moment guidance and emergence situations. These phone calls are designed and structured in such a way as to help teach the patient how and when they should ask for help; asking for help in the earliest stage of a crisis before it snowballs into something bigger. This allows the therapist to assist before the patient has engaged in a negative behavior such as self-harm.
These phone calls typically occur as and when needed, although the therapist may place boundaries on certain times for the sake of their own mental health.
Therapist Consultation Team
There are typically between three to eight therapists within the DBT consultation team and they will meet regularly – often weekly – to discuss where they are at with their patients and their own responses to how sessions are going. Therapists can discuss potential strategies with one another on how best to help a patient from where they are currently at.
These session are also a form of self-therapy for the therapy team. Treating people with borderline personality disorder can be incredible stressful and the team consultation allows the therapists to help one another manage the stress and strain this can put on their own lives.
Patients do not attend these meetings.
How effective is dialectical behavioral therapy for treating borderline personality disorder?
77% of people who underwent DBT to treat BPD no longer met the criteria for borderline personality disorder after the conclusion of treatment. This is an astonishing rate of recovery and is exactly with dialectical behavioral therapy is considered the gold standard for treatment of borderline personality disorder.
Treatment typically takes at least six months to a year. Depending on a variety of factors though, the treatment can take several years. It’s important to remember that “getting better” at anything is seldom a straight upwards line - there are always peaks and troughs – and therapy is no different.
Questions to ask a therapist before visiting them
Before you visit a therapist to seek treatment for borderline personality disorder, it’s important to make sure they are the right therapist to help you improve your mental health. Choosing the wrong therapist can cost you time, money and your mental health so it’s important to ask questions and get a feel for them before you make an appointment.
Important questions include:
- How experienced are you in treating people with borderline personality disorder?
- What is the nature of your training in dialectical behavioral therapy?
- Do you work with a DBT consultation team?
- How many patients with similar issues to mine have you treated ?
- Do you accept phone calls and emails during the working week?
- What is the best way to contact you if I’m having a mental health emergency?
- How often would you want to see me and how long do you anticipate treatment taking?
- What is your typical session like and how long does it last?
- How much do you charge for a session?