When to Use Dialectical Behavior Therapy

Dialectical Behavior Therapy (DBT) was developed by psychologist Dr. Marsha M. Linehan to assist in the treatment of people who were dealing with very severe suicidal thoughts.
The method of DBT was developed specifically to assist in the treatment of these tough patients by addressing their rather paradoxical responses to standard forms of intervention. The treatment became very popular and found significant use in treating a severe personality disorder, borderline personality disorder, also notoriously unresponsive to therapy.

Following its recommendation as the first-line treatment for borderline personality disorder, the principles of DBT were also applied to other behaviors/psychological disorders that are difficult to treat in therapy. It is currently used for a number of other treatment issues.

The Principles of DBT

healthcare and medical - young team or group of doctorsClients who are suicidal or who have severe personality disorders are often extremely tough cases in therapy. These clients will typically become reactive to efforts to get them to change their thinking, attitudes, or actions. At the same time, they will become equally reactive at attempts to get them to accept aspects of the world that contribute to their attitudes, actions, or behavior.

When therapists attempted to get these individuals to change their attitudes and/or behaviors that cause them distress, these clients would often shut down emotionally and offer little effort into the therapeutic process. When therapists would attempt to get them to accept aspects of the world that they were totally powerless to change, these clients would often become aggressive to the therapist. The result was that many of these clients would typically remain in therapy for a short period of time, become aggressive and hostile to the therapist, drop out of therapy altogether, or find another therapist. This became a frustrating situation for both the therapist and the client. DBT was specifically designed to treat these types of clients.

Neurons in the brainDBT attempts to synthesize these two opposite states and bring them together in the therapeutic environment (hence the word dialectic, a synthesis of two opposite points of view). DBT does this by engaging in three mechanisms to assist clients to synthesize their conflicting issues with changing certain behaviors and with the acceptance of reality:

DBT embraces a supportive approach that helps clients identify their strengths and then approaches the need to change certain aspects of their attitudes and behaviors, and to accept other aspects of the world based on the client’s strengths.

Because DBT is a form of Cognitive Behavioral Therapy, it focuses on the person’s cognitions, or thinking processes, that play into the formation of belief systems, personal assumptions, and assumptions about the world. By assisting the client in changing certain irrational beliefs and assumptions about oneself, other people, and one’s future, DBT can effectively promote behavioral change.

DBT stresses the use of the therapeutic alliance (the working bond between the client and therapist) in therapy. DBT also stresses forming an alliance between the client, the therapist , and other people who are important in the client’s life to assist the client in making changes and to accept things that cannot be changed.
The focus of change in DBT is to attempt to change aspects of the self (attitudes, expectations, and behaviors) that are actually changeable and to accept aspects of the world that one cannot control or change. DBT assumes that change is important for growth and establishes a focused approach to implementing change.

The DBT Approach

The DBT approach is multidimensional and comprehensive. Several mechanisms of therapeutic intervention converge to produce both change and acceptance in the individual.

  • DBT helps to motivate clients to change aspects of their lives that they can change.
  • Because many individuals are afraid of change, it is important to assist them in developing the capability to change certain aspects of themselves and at the same time identify aspects of themselves and others that they cannot change.
  • DBT assists clients in the development of more functional behaviors and helps them apply these in real-world situations.
  • Therapists provide an environment in the therapy sessions that encourage self-confidence, gives clients tools to help effect change, and prepare clients for situations that will occur in the real world.
  • Therapists ensure that they remain motivated and competent in their delivery of therapy with continued training and consultation with other therapists.

DBT uses a number of delivery methods to meet its goals. Clients will participate both in individual therapy and in group therapy (see below). In addition, clients can utilize on-the-spot phone consultations with therapists to address situations that occur out in the real world. Therapists continue to sharpen and hone their skills and abilities via the use of motivation therapy and skills training.

Components of DBT

DBT is not a singular approach. As mentioned above, it utilizes multiple components to complement one another. These include:

Individual therapy sessions for the client are typically held on a weekly basis with the therapist. In the sessions, the therapist and client work together to increase the client’s motivation to change certain aspects of thinking and behavior, and to learn and develop new skills to address the specific challenges faced by the client. Individual sessions will continue for the duration of the therapy.

DBT also utilizes group therapy sessions that are typically skills training groups. In these groups, individuals with similar problems/diagnoses will meet with a therapist who will teach skills to facilitate changes or to accept certain aspects of the world. These groups typically meet weekly for periods of 90 minutes to 3 hours, depending on the subject matter and size of the group. There is a full psychoeducational curriculum that will usually take 20-24 weeks to complete. The curriculum then is repeated in order to give individuals the chance to re-attend either all of it or just certain areas that may be particularly troublesome for the individual. The educational aspects of the group are targeted toward the specific problems or the symptoms of the psychological disorder that is being treated, and can include things like coping skills, relaxation techniques, conflict resolution, anger management, issues dealing with substance abuse, etc.

Phone coaching is designed to offer clients immediate solutions/assistance with particularly difficult issues that may arise on the spot. Clients can phone their therapist, or another therapist who is available, and discuss the issue. Of course, this service has the potential to be abused by clients and certainly needs to be used with discretion.
Consultation teams are designed to update the therapist regarding research findings, the implementation of new techniques/approaches, and to sharpen their skills. These consultation teams can increase motivation, particularly for therapists who have trying case loads, and allow therapists a venue to discuss tough cases, compare methods, get support from each other, learn from each other, and so forth.

By using supportive, multilevel, and focused approaches, as well as requiring therapists to receive continuing education, DBT delivers a comprehensive treatment package. Therapists remain motivated to help clients and are updated regarding the latest techniques and strategies for doing so.

DBT recognizes that clients entering treatment will typically have a number of different problems that need attention. It is important for the therapist to evaluate the individual and understand the specific issues that affect the person. DBT focuses on ensuring that the treatment follows empirically validated protocols but at the same time approaches each client as an individual. The therapist will adjust the sessions to the needs of the individual. DBT therapists attempt to prioritize their approach such that:

Very serious or even life-threatening issues, such as being suicidal or having a significant substance use disorder, are addressed first.

Actions that are counterproductive to improving in therapy, such as missing a significant number of individual or group therapy sessions, showing up late for sessions, canceling appointments, not completing homework assignments, causing dissent in group sessions, etc., are addressed next. Many of the types of clients who were originally treated with DBT, such as suicidal individuals or individuals with borderline personality disorder, often engage in behaviors counterproductive to success in therapy. In DBT, these behaviors are addressed directly.

Circumstances, behaviors, and other factors that increase the person’s quality of life are addressed next. These can include relationship issues, communication issues, psychological problems such as depression, work issues, etc.

Teaching, acquiring, and developing new skills to act in place of skills or behaviors that are contrary to the individual achieving life goals are worked on next.
The therapy attempts to address issues in the order of their impact on the client’s life. The therapist will address as many different issues as needed to satisfactorily help the individual reach goals. This ensures that the treatment package is individualized and comprehensive.

DBT offers a combined approach of both group and individual therapy, on-the-spot consultation, and a synthesis of a number of different paradigms in psychology, such as:

  • Advantages of both group and individual therapy
  • The cognitive behavioral paradigm
  • Stress reduction
  • The crisis intervention model
  • Psychoeducation

DBT can be combined with other forms of treatment, including medication-assisted treatment for individuals with substance use disorders, psychiatric intervention if the individual needs other medications, support group therapy such as 12-Step groups, etc.

Relapse prevention therapy for individuals with severe substance use disorders can be used in conjunction with DBT.

Even though DBT attempts to help individuals develop motivation, the DBT package can also be combined with Motivational Interviewing to ascertain where the person stands in the process of change and motivate the person to engage in change.

Certain types of behavioral therapies can be incorporated into DBT to assist individuals with anxiety or with response prevention therapy for obsessive-compulsive types of behaviors.

DBT can be combined with other types of therapeutic approaches, such as the psychodynamic approach, if individuals want to learn more about complex motivational factors that drive behaviors.

Who Is Qualified to Perform DBT?

DBT is a form of psychotherapy. As a form of formal psychotherapy, it can only be practiced by a qualified, licensed, mental health professional. Thus, the first requirement for those wishing to practice DBT is that they complete a formal, advanced degree in psychology, social work, counseling, psychiatry, etc. After obtaining an advanced degree, individuals must become licensed to practice therapy in the state they are intending to practice in.

After completing the formal requirements to practice therapy (or even during the process of completing these requirements), individuals must receive specific training in DBT techniques and the DBT process. DBT cannot be learned via secondary sources, such as reading a few articles or books. Individuals who practice DBT should have completed the above training and should also complete a formal course of supervised training in DBT. Individuals who have completed such training will have advanced degrees in one of the above-mentioned disciplines; a formal state license identifying them as a licensed professional psychologist counselor, social worker, etc.; and a formal set of certificates authorizing them to practice DBT.

Any individual who seeks a competent therapist trained in DBT has the right to ask the therapist for credentials, inquire about training, and ask about the techniques the therapist intends to employ. In addition, individuals can inquire about therapists through their state board of mental health or through any state professional organizations.

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