What is Dialectical Behavioral Therapy and Why Is DBT Effective?

What if I told you that DBT had me come full circle in my approach to practice as a therapist?

I first learned about Dialectical Behavioral Therapy, DBT, in my final year of graduate school in a transpersonal psychology program, where I wanted to approach psychology from the soulful, the unknown, the mysterious, and the beyond. DBT was one segment of our Cognitive Behavioral Therapy (CBT) course.

I appreciated and valued the science of psychology, but had a knee-jerk opposition to a strict focus on Cognitive Behavioral Therapy (CBT) to heal clients. Somehow CBT seemed too superficial, too measured, and too demanding as a healing practice. As a former lawyer, I was tired of the uber-rational, the rules, and the norms. I favored approaching therapy, as healing, and as more art than science.

I have since come to see that DBT integrates both art and science, the rational and the emotional, the body and the mind, the many and the One. It is a constant search for both/and, not either/or solutions to dilemmas, and how we view and respond to problems. So enamored in its approach was I that I became trained in its skills and foundations and have the privilege of offering DBT to the teens, adults, and couples that I work with.

What DBT Therapy Is All About

DBT is a mix of CBT, behaviorism, and mindful practices, recognizing the importance of both the rational and the emotional realms of life. DBT seeks a middle path, inviting us to use our “Wise Mind” as the north star when engaging with each other and the world.

DBT was developed by Marsha Linehan, Ph.D., an accomplished psychologist, researcher, and transformational leader. Stories of Linehan’s wit, skill, and tenacity abound. I invite you to pick up a copy of her Cognitive- Behavioral Treatment of Borderline Personality Disorder (1993) to see how both she and DBT evolved in the field.

Dialectics

From the point of view of dialogue and relationship, Linehan described the dialectics in DBT as:

“… change by persuasion and by making use of the oppositions inherent in the therapeutic relationship, rather than by formal impersonal logic.”

Given that many among the population most served with DBT have been subject to severe trauma, DBT starts with whatever challenges the client presents with, and seeks to find new meanings within old frameworks, creating synthesis from thesis and antithesis.

In DBT, the therapist utilizes contrasting skills -- sometimes coaching, sometimes the devil’s advocate position, and sometimes radical acceptance. Clinicians understand trauma and that all of us are capable of extremes. Therapists accompany clients as they learn to manage uproars and soothe other difficult feelings that can emerge suddenly, or out of the blue.

DBT shows clients that change takes something. It’s rarely a cup of tea. Sometimes you have to do the exact opposite of what your strongest urge wants to do. DBT assumes the client is capable, not fragile, and fully capable of change; but also assumes that, until awareness and skills are practiced and internalized, failures can occur. DBT skills are taught to ensure clients don’t make a bad situation worse.

Clients discover that, even if they didn’t cause their intolerable circumstances, they have to live with them. They can try to solve their problems, look at them differently, radically accept them as they are, or stay miserable.

Emotional Regulation, Distress Tolerance, & Interpersonal Effectiveness

DBT works well for those who rampage or fly out of control, with words, deeds, substance use; and emotions; and for those who zoom from a 3 to 4 to a 9 or 10 on the overwhelm/outrage scale, in a split second, and stay there longer than is effective.

Clients seeking DBT may find themselves in constant challenges with others, their finances, their health, their safety, their stability, their careers, school, relationships, and resources. They may find they suffer so much loss, they inhibit grieving, moving from one relentless crisis to another.

While DBT validates that trauma, when untreated, may create chronic states of emotional dysregulation, and that such states may lead to impulsive, dangerous, and ineffective behaviors, it pulls for strength and resilience. It attempts to make lemonade out of lemons.

Biology and Behaviorism

DBT helps clients, partners, and parents shape new behaviors, extinguish ineffective ones, and discern what may be keeping troubling interactions in place.

DBT clients benefit from the treatment focus on educating clients and families about the biology of trauma and dysregulation, nature, function, and urges of emotions, and the vital need for validation and soothing in our lives.

DBT Skills

DBT Skills comprise four modules: Mindfulness, Interpersonal Effectiveness, Emotional Regulation, and Distress Tolerance. Skills are often taught in groups of 3 or more participants. Each module is covered in approximately 6-8 weeks, with a course of DBT-adherent therapy typically running a course of six months or more.

Skills are trained in simple, elegant, and practical ways. They have catchy acronyms that come in handy when you need one in a snap (like when your emotional engine is running way too hot and you are heading into a meeting). Homework and group participation reinforce skills training, and inter-session coaching offers opportunities to keep clients on track.

I like DBT, because it is humane, practical, reinforcing, and effective. For the most seriously challenged clients, DBT research finds that DBT reduces episodes of suicidality and self-harm, hospitalization stays, and dropouts from therapy. Client testimonials further attest to its efficacy, and nothing beats seeing results on the ground.

Who is DBT Most Effective With?

DBT Treatment is not only for suicidal or deeply traumatized individuals and has multiple stages of treatment, ranging from the most life-threatening (stage 1) to what seems to me to be the most existential/spiritual (stage 4).

DBT Adherent treatment typically involves a comprehensive packet of services including personal therapy, DBT Skills Training, Phone Coaching, and DBT Consultation for the Therapist. DBT therapists may use the DBT Skills book and diary cards to reinforce principles and measure progress/regression. Diary cards also provide an efficient way for the therapist to gain a birds-eye view of the client’s life between sessions.

The interest in DBT seems to be growing. In fact, MSNBC’s Morning Joe recently aired an interview with two prominent DBT experts touting their new DBT for Dummies book. A link to the segment can be found here.

Hopefully, this whets your appetite to hear more about DBT. For questions as to how DBT might serve you or someone you love, please call Carla Barrow, LMFT at 954-391-5305 for a complimentary consultation in English or Spanish.

And keep your eyes out for future articles on how I use DBT to enhance Couples Therapy.