Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT)

“Dialectical Behavior Therapy” (DBT) was developed by Marsha Linehan for the outpatient treatment of chronically suicidal patients with borderline personality disorder.

It is based on:

• A biosocial model of etiology
• Cognitive-behavioral treatment strategies
• Specific therapeutic “dialectical” intervention methods

Individual therapy and skills training in group settings complement each other to form an overall concept whose superiority over non-specific forms of therapy has been empirically demonstrated.

In her manual, Linehan supplements cognitive behavioral therapy with elements from humanistic therapeutic approaches, hypnotherapy and, in particular, from Zen.

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Individual Therapy

In individual therapy, problem areas are hierarchically ordered by urgency:

1. Suicidal and parasuicidal behavior (highest priority)
2. Therapy-interfering behavior
3. Impairments to quality of life
4. Improvement of behavioral skills

The problem areas are addressed in this order. If necessary, the focus immediately returns to a higher level.

Dialectical Strategy

The individual therapist attempts to find a balance between validation strategies (understanding and valuing the problem) and change strategies.

Diary Card

Patients keep a diary card in which they record:

• Medication intake
• States of tension
• Drug use
• Dysfunctional behaviors

Behavioral Analyses

Through behavioral analyses, affected persons are meant to gain insight into the build-up of tension and learn to incorporate what was learned in skills training into action plans.

Trauma Processing

A prerequisite for the potential processing of trauma in a second phase of therapy is that patients have learned to regulate emotional crises, states of tension and dissociations through the skills they have acquired.

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Skills Training

“Skills training is the clay from which the individual therapist and patients can model a figure.” - Marsha Linehan

What is meant is that the skills learned in the group are built into the behavioral analyses and action plans developed in individual therapy and connected into a meaningful whole.

The group is led by two therapists. The emphasis is on teaching skills. Criticism and suggestions from participants are expressly welcome - an experimental-partnership atmosphere should develop.

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The Four Modules of Skills Training

1. Mindfulness

In the “Mindfulness” module, patients learn:

• Observing
• Describing
• Participating
• Non-judgmental, focused and effective thinking and acting

Here the Zen influences are clearly recognizable. The goal is to achieve awareness in everyday life and to gain more control over oneself. Participation and distance, feeling and reason are to be brought into harmony with each other.

2. Interpersonal Effectiveness

Here the basic skills are taught:

• Orientation toward a goal
• Orientation toward self-respect
• Orientation toward the relationship

Factors that impair social competence and those that promote it are identified. Supportive self-statements are developed.

Goal: Patients should be able to insist on their own wishes, goals and opinions while being respected by others and maintaining their own self-respect.

3. Emotion Regulation

Here it is conveyed that emotions (including those experienced as unpleasant) have a function and a meaning.

Skills:

• Observing, describing and understanding emotions
• Reducing vulnerability
• Taking steps toward pleasant emotions
• Letting go of emotional suffering
• Acting opposite to the emotion

Goal: Learning to understand and accept emotions in their meanings and effects. Trust in one’s own emotional world is to be increased.

4. Distress Tolerance

Here patients learn to endure crises and reduce tension through techniques such as:

• Distraction through strong sensory stimuli (skills): e.g., ice cubes
• Improving the moment: various techniques
• Pros and cons: What arguments speak for/against self-harming behavior?
• Accepting reality
• Breathing exercises
• Half-smile
• Mindfulness exercises

Emergency Kit

Patients are guided to set up an individual emergency kit containing important supplies for distress tolerance skills. Cards on which the most helpful skills are noted should be carried by the patients at all times.

Further goal: Learning to endure unpleasant events and feelings when the situation cannot be changed.

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Telephone Contact

Patients can call their therapists in suicidal crises or before harming themselves. Telephone availability must be clarified with the therapists in advance.

Procedure for a Crisis Call

1. Patient reports why they are in a crisis
2. Patient names which skills they have already tried
3. Both discuss skills that the patient should then apply

Important

If the patient harms themselves or makes a suicide attempt, this should not be reinforced through increased attention. The goal is for patients to subsequently produce behavioral analyses of these situations.

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Further Information

• Overview of Therapy Forms
• Self-Help and Crisis Intervention
• Clinics with DBT Programs