Introduction to Dialectical Behavioural Therapy

Dialectical Behavioural Therapy (DBT) was initially developed to treat suicidal patients and those diagnosed with Borderline Personality Disorder (BPD). Over the years, DBT has been adapted for other complex mental health issues, like self-harming, substance abuse or eating disorders.

This form of psychotherapy uses a cognitive-behavioural approach, joining it with mindfulness-based techniques derived from eastern Zen Buddhism and Western contemplative practices, creating a stimulating and refreshing dynamic.

This combination allows patients to do both: introduce crucial changes in their lives while accepting their current state without judgement. The element of acceptance is seemingly the opposite of the one of change. However, DBT focuses on removing the tension between them and maintaining a sense of balance. It integrates acceptance and change, creating an innovative solution, or in this case, a synthesis.

The basic premise of DBT states that there are people who exhibit a higher level of arousal in certain emotional situations, usually regarding friends, family or romantic relationships. They also encounter various issues because of the lack of crucial distress tolerance, interpersonal and self-regulation skills. What usually follows such stimulation is a tendency to react in a quick, intense and abnormal manner and take an extended time to recover afterwards. The profound emotional swings lead to perceiving the world in opposites, black-and-white, not leaving any space for grey areas.

DBT addresses these issues throughout the treatment, equipping patients with essential skills that enable them to ride the wave of crisis rather than being swallowed by it.

The Beginnings of DBT

Dialectical Behavioural Therapy was created in the 1970s by a PhD psychologist, Marsha Linehan, who tried to find an effective treatment for chronically suicidal patients and those with the diagnosis of Borderline Personality Disorder (BPD) since the traditional Cognitive Behavioural Therapy was not working for them.

Linehan wanted to tackle the problems of emotional dysregulation and self-destructive behaviours, typically linked to Borderline Personality Disorder. She noticed that most patients with this diagnosis faced many emotional challenges while growing up in an emotionally abusive environment, being misunderstood and invalidated. The traditional CBT treatment does not acknowledge those difficulties. Therefore, such patients are more likely to show resistance and eventually withdraw from therapy.

As an effect of this insight, DBT addresses these issues by validating and radically accepting clients’ current emotional needs and behavioural functioning. It does so by using mindfulness-based techniques instead of exclusively trying to change them, as it is practised in CBT.

The treatment has also been divided into three components (individual sessions, group skills training, telephone contact with a therapist) dedicated to different therapy aspects.

Various Skills Developed In DBT

According to DBT, people struggle to achieve a sense of mental wellbeing due to the lack of essential skills. Throughout the treatment, clients work on developing these skills divided into four modules:

Mindfulness

We often tend to be preoccupied with our past or future, being disconnected from the present moment. Through practising mindfulness-based techniques, such as meditation or diaphragmatic breathing, clients turn their attention to the here and now in a non-judgemental manner. They learn to observe and describe their feelings without over-engaging with the emotional states. DBT therapists also explain the human mind’s versatile nature, where the reasonable, emotional and wise elements collide. Clients learn how each of them is useful in different situations and how to balance them out in the present moment. Interpersonal Effectiveness

This skill boils down to navigating the meanders of social life respectfully and assertively. The skills training emphasises the importance of applying the theory in practice, especially in emotionally challenging or unpredictable situations. In this module, clients can learn how to formulate requests or healthily set their boundaries, supporting their relationships with others and themselves.

Emotional Regulation

People with suicidal behaviours or Borderline Personality Disorder often struggle with intense emotions, including frustration, anxiety, and depression. Having a sense of awareness and understanding of those feelings can help significantly in gaining control over them. This module of treatment aims to develop the ability to identify and name emotions, induce self-awareness of emotional states experienced in the present moment and use distress tolerance skills. In the long-term, emotional regulation skills foster an increase in experiencing positive feelings.

Distress Tolerance

This module stems from mindfulness skills since its main objective is handling pain gracefully and consciously. The main lesson here focuses on the fact that suffering is a natural part of human existence. The best way to approach it is to unconditionally accept the current state of the self and the world in a non-judgmental fashion. The clients train their ‘distress tolerance’ muscle using appropriate techniques that replace previous inadequate coping mechanisms such as self-injurious behaviours. Possessing this skill facilitates approaching future problems with an open mind and lower levels of anxiety or anger.

Acceptance and Change Techniques 

The dialectical manner of DBT focuses on the concept of integrating the two opposites into a synthesis – a solution that supports the growth and healing of patients. Acceptance strategies validate the experiences of the client, whereas change strategies question them later. DBT therapists are trained in simultaneous challenging the unhelpful patterns of thoughts or behaviours and motivating clients to establish new and improved skills to cope with daily life. Change techniques applied in treatment help clients replace destructive behaviours with effective and healthy ones that support personal growth. Actual progress can only begin in a place of radical acceptance. Only when we acknowledge our current state and recognise the unhealthy ways of functioning is it possible to direct our actions towards change for the better. DBT conveys a beautiful message that balancing between the two is essential in the process of healing.

What does DBT treatment look like in practice?

DBT is a treatment that occurs in 4 stages. Each of them focuses on different priorities that address the specific needs of clients. 

Stage One

The biggest priority is keeping clients alive and addressing their suicidal or self-harming behaviours. These issues need to be taken care of before any therapeutic work can begin. Clients with suicidal ideation and BPD tend to interfere with the treatment. Once their state is stable and secure, the therapist’s task consists of removing any resistance to treatment. That can be demonstrated by coming late to sessions or missing them entirely. The last objective of stage 1 is dealing with various quality-of-life situations that can impede the course of the treatment, such as substance dependence or unemployment.

Stage Two

That portion of the therapeutic process encourages the appropriate expression of uncomfortable feelings and emotion through learning different mindfulness skills. Treatment is centred around replacing suppressing or avoiding challenging emotions with experiencing them in a proper manner.

Stage Three

A valuable lesson of stage three is understanding the fact that experiencing various issues and feeling unhappy is a normal and unavoidable part of life. The treatment here aims to equip clients with problem-solving techniques that help them cope with day-to-day challenges without perceiving them as severe crises. A skill of reducing these problems eventually fosters a better quality of life.

Stage Four

By the end of the therapeutic process, clients have acquired the necessary skills to navigate the ebbs and flows of daily life. However, they can still struggle with feeling like something is missing. Treatment then focuses on experiencing the sense of completeness and maintaining wellbeing and happiness later in life.

Individual Therapy Sessions

The emphasis of the one-on-one sessions with a DBT therapist centres around the objectives discussed in the section above – stages of treatment. It additionally stresses the significance of properly cope with emotional trauma. The therapist’s role also revolves around increasing client’s self-image by supporting and reinforcing their adaptive behaviours as they’re happening in the therapeutic process. The weekly session, on average, lasts for 1 hour. It’s also worth mentioning that having telephone contact with the therapist between the sessions is a part of upgraded DBT procedures.

Group Skills Training

DBT therapists, usually two, deliver the skills training for groups. The weekly sessions are generally 2,5 hours long. They’re aimed at teaching participants four modules of relevant skills to be applied in daily life through different group exercises like role-playing and doing homework assignments.

What is DBT effective against?

DBT is a treatment tailored to the needs of people with chronic mental health issues for whom other types of therapy did not work. It was originally developed for patients with Borderline Personality Disorder, self-harming behaviours and suicidal ideation. Currently, the majority of research on the effectiveness of DBT focuses on these mental health issues. One of the first studies published on DBT (Linehan et al., 1991) shows how the treatment positively impacts the mental state of a difficult-to-treat population. After a year-long DBT treatment, a group of suicidal women diagnosed with BPD and a history of self-injurious behaviour displayed a smaller amount of suicide attempts, a smaller amount of inpatient psychiatric days, and most importantly, higher willingness to continue individual therapy afterwards. People who struggle with substance abuse, post-traumatic stress syndrome, eating disorders, ADHD, bipolar disorder can benefit from the treatment offered by DBT.

DBT especially helps overcome bulimia nervosa and binge eating disorder, where emotional dysregulation is at the core of the suffering. Treatment helps patients gain an understanding of their unhelpful thinking patterns and equips them with skills essential to cope with uncomfortable and painful emotions in a healthy, non-destructive way. As a result of DBT, the symptoms connected to these eating disorders (diagnostic remission) are reduced by more than 60%.

DBT can also help adolescents and young adults struggling with emotional dysregulation as well as middle-aged and senior individuals diagnosed with depression.

If you’re willing to commit to introducing and maintaining a lasting change in your life through working in the present moment in both individual and group sessions, Dialectical Behavioural Therapy can be a good fit for you. 

Who can practice DBT? 

Currently, in the UK, an official list of registered DBT therapists does not exist. Nevertheless, becoming a certified DBT therapist means finishing DBT Training Courses. Future professionals gain knowledge of different theories and protocols applied throughout the therapeutic process. Before starting Dialectical Behavioural Therapy, make sure that your therapist is a licensed healthcare professional.

DBT – NHS

DBT stems from traditional Cognitive Behavioural Therapy; therefore, it is refunded by the NHS. Once your doctor gives you the NHS referral, you can look for your local DBT treatment. Unfortunately, DBT therapists are not yet officially registered in the UK. 

The access to DBT is limited, and waiting lists tend to be rather long. If you can afford it, DBT treatment is also available in the private sector.

DBT vs CBT

Even though DBT originated from Cognitive Behavioural Therapy, it does differ significantly. The most significant distinction between the two forms of psychotherapy concerns the approach in addressing the clients’ unhelpful ways of functioning.

CBT puts focus mainly on recognising and solving problematic, destructive behaviour patterns. It does so by restructuring client’s negative beliefs into healthy and efficient ones. DBT recognises the importance of the radical acceptance of the client’s current state and acknowledges their efforts to cope with mental health issues.

Emphasising the non-judgmental acceptance of clients validates their experiences without discrediting them. That not only prevents clients who are challenging to treat, such as individuals with BPD, from withdrawing from therapy. It also provides them with a sense of understanding and encourages them to continue engaging with the treatment.

Another innovation introduced in DBT is a weekly training of interpersonal skills in a group setting. That, in turn, increases the client’s psychosocial abilities in the long-term.

Lastly, DBT pays a lot of attention to the relationship between the client and the therapist. Only when the clients feel good and comfortable during individual sessions can the therapists form expectations and encourage them to implement essential changes in their lives.

Last updated at: 2021.05.04