UNDERSTANDING
“DIALECTICAL BEHAVIOUR THERAPY”
By: Jessica Joanes
CONTENTS
• Introduction.
• History.
• Function of DBT.
• BIO- social Theory of BPD.
• Modes od DBT.
• Advantages of DBT.
• Dis-advantages of DBT.
• Results.
• References.
Introduction to DBT
• Dialectical Behavior Therapy(DBT) is a multi-
modal, cognitive-behavioral treatment
originally developed to treat women who meet
criteria for Borderline Personality Disorder
(BPD) with a history of chronic self harm and
suicide attempts.
• DBT is an effective treatment for people who
have difficulty controlling their emotions and
behaviors.
What Does "Dialectical" Mean?
Dialectical two opposite ideas can be true at the same
time, and when considered together, can create a new
truth and a new way of viewing the situation.
There is always more than one way to think about a
situation.
HISTORY
• DBT was developed by Marsha Linehan at the University of
Washington in 1970s.
• For years she had used standard CBT strategies to work with
suicidal and actively self-injurious patients.
• They discovered that cognitive-behavioral therapy alone did
not work as well as expected in patients with BPD.
• However, Linehan found that therapists' unrelenting focus
on trying to help patients change their problematic behaviors
often led patients to feel invalidated.
• The first randomized controlled trial (RCT) for DBT was
published in 1991.
DBT might be an effective treatment for:
• Attention-deficit/hyperactivity disorder
• Bipolar disorder
• Eating disorders
• Generalized anxiety disorder
• Major depressive disorder
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Substance use disorder
Borderline Personality Disorder (Diagnostic Criteria
according to DSM 5)
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity,
beginning by early adulthood indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment.(Begging,threathing self-harm)
2. A pattern of unstable and intense interpersonal relationships(their relationship can change quickly)
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.(they often feel confused of
who they are)
4. Impulsivity in at least two areas that are potentially self-damaging (e.g.. spending, sex, substance abuse, reckless
driving, binge eating).
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.(often hurting themselves or talking
about suicide)
6. Affective instability (e.g., They experience intense, rapidly changing emotions, especially angry, anxiety or
sadness, often triggered by small events).
7. Chronic feelings of emptiness.(they often feel empty inside like something is missing or that life is meaningless)
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger,
even physical fights over small issues).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.(eg, feel disconnected from reality)
• BPD is a severe, costly, and difficult-to-treat psychiatric disorder.
• Most individuals diagnosed with BPD report high rates of nonsuicidal
self-injury (NSSI) and multiple suicide attempts.
• The lifetime mortality rates by suicide are estimated to be 50 times
higher among BPD patients compared to the general population.
• According to the American Psychiatric Association there is no single
efficacious pharmacological intervention for BPD.
• However, current practice guidelines recommend psychotherapy as
the primary treatment for BPD.
• DBT is the psychosocial treatment that has received the most
empirical support for patients with BPD
Functions of DBT
1. To enhance and expand the patient's repertoire of skillful behavioral
patterns.(eg, mindfulness, emotion regulation and distress tolerance)
2. Many problematic behaviors (e.g., self-harm, angry outbursts) are
negatively reinforced because they temporarily reduce pain or stress.
DBT reduces this by helping the patient develop better coping
strategies and increasing their motivation to use them.
3. To ensure that new behavioral patterns generalize from the
therapeutic to the natural environment.
4. The environment (including family, friends, and therapists) is
shaped to encourage healthy behaviors and not support harmful
ones.
Biosocial theory of BPD
• Invalidating environment
• Emotional vulnerability
• Emotional Dysregulation
Invalidating environment
This refers to surroundings (like family, school, or peers) that
consistently dismiss, punish, or ignore a person's thoughts,
feelings, or emotional needs. For example, a parent may
pervasively communicate
"You're not that upset, you're just faking it" or
"You say no, but you don't really know what you want.“
(This teaches the person to mistrust their own emotions and not
know how to express or regulate them)
Emotional vulnerability
This means the person is biologically more sensitive
to emotions and finds it harder to return to emotional
balance.
It involves:
a. Heightened sensitivity: Easily triggered by
emotional stimuli (small things feel very big).
b. Intense emotional reactions: Feelings come on
strongly and quickly.
c. Slow return to baseline: Takes a long time to
calm down once upset.
This makes the person more reactive to stress and
emotional overwhelmed.
Emotional Dysregulation
This refers to the difficulty in managing and modulating
emotional responses.
Specifically, it is: An inability to readily increase or decrease
physiological arousal, meaning that a person cannot easily calm
down or manage intense emotions.
This difficulty can result in extreme behavioral dyscontrol, which
includes:
• Self-injurious behavior (e.g., cutting, burning)
• Impulsivity (e.g., risky sex, reckless driving)
• Aggression (e.g., outbursts, fights)
In people with BPD, emotional dysregulation is not just about
feeling emotions intensely, but about not having the tools or
capacity to return to a calm state after being emotionally triggered.
Modes of DBT
The four modes of treatment in DBT are as follows:
(1)Group skills training
(2)Individual therapy
(3)Phone consultations
(4)Consultation team
Group Skills Training
• Patients learn specific behavioral, emotional, cognitive, and interpersonal skills.(manage
behaviors, handle emotions, change negative thinking patterns and improve relationships)
• In standard group therapy, members often discuss each other's experiences and offer
feedback. In DBT group skills training, this is discouraged to:
(Keep the focus on learning and practicing skills, Avoid triggering or judging others' emotional
issues)
• Rather, a didactic approach, using specific exercises taken from a skills training manual is
used. The group is run more like a classroom than a therapy circle. Facilitators teach skills
using handouts, practice exercises, homework assignments, and role plays. It's structured
and educational, not exploratory or interpretive like traditional group therapy.
• Many of which are geared toward control emotional dysregulation and impulsive behavior.
The main focus is to help individuals: Regulate intense emotions that feel overwhelming,
Avoid acting impulsively (e.g., self-harm, explosive anger),Skills target building self-control
and emotional stability
A)Skills Modules: Mindfulness: It is the practice of paying attention
in a particular way: on purpose, in the present moment, and
without judgment.
B)Skills Modules: Distress Tolerance: self-injurious behavior may
function temporarily to reduce distressing emotional states.
The distress tolerance module is designed to teach patients how to
tolerate aversive emotional experiences without behaving
maladaptively.
S-top
Do not just react. Stop! Freeze! Do not move a muscle! Your emotions may try
to make you act without thinking. Stay in control
T-ake a step back Take a step back from the situation. Take a break. Let go. Take
a deep breath. Do not let your feelings make you act impulsively.
0-bserve Notice what is going on inside and outside you. What is the
situation? What are your thoughts and feelings? What are others saying or
doing?
P-roceed mindfully Act with awareness. In deciding what to do, consider your
thoughts and feelings, the situation, and other people's thoughts and feelings.
Think about your goals. Ask Wise Mind: Which actions will make it better or
worse?
C) Skills Modules: Emotion Regulation: This is designed to help
patients to better understand their emotions, reduce emotional
vulnerability, and decrease emotional suffering.
D) Skills Modules: Interpersonal Effectiveness: Patients are taught
what to say and how to say what they say depending on their
priority in an interpersonal situation.
Individual Therapy
• Sessions in DBT are held weekly, generally for 50 to 60 minutes, The
therapist helps review how well the patient used DBT skills in the past
week and how they dealt with real-life events.
• Special attention is given to behaviors that were harmful or unhelpful.
Therapists explore how using DBT skills could have changed the
outcome.
• Patients track their emotions, behaviors, and use of DBT skills on diary
cards. These are used in sessions to guide discussions and therapy goals.
Telephone Consultation
• Therapists are available for phone consultation 24 hours per
day.
• Patients are encouraged to call when they feel themselves
heading toward some crisis that might lead to injurious
behavior to themselves or others.
• Calls are intended to be brief and usually last about 10
minutes.
Team consultation
1. Weekly Therapist Meetings:DBT therapists meet regularly to
discuss their patients and treatment strategies.
2. Mutual Support & Motivation: These meetings help therapists
support each other emotionally and stay motivated. It's
especially helpful when dealing with challenging cases.
3. Technique Comparison and Validation: Therapists share
which techniques worked well and which didn't. This
improves overall treatment quality and skill-building across
the team.
Consultation team agreements in DBT
1. Weekly 1-2 Hour Meetings : The team meets consistently for collaborative case
discussions.
2. Follow Treatment HierarchyThey prioritize treatment according to severity:
1st: Self-harm or life-threatening behavior
2nd: Behaviors that interfere with therapy
3rd: Behaviors affecting the patient's quality of life
3. Dialectical Philosophy :Therapists agree to adopt a dialectical stance: balancing
acceptance and change.
4.Coordinate Care Respectfully :Therapists plan how to interact with other professionals
involved in the patient's care. They don't interfere with each other's therapeutic relationships
with the patient.
5. No Expectation of Consistency Across Therapists :Therapists recognize that differences
approach are normal.
Advantages Of DBT
1. Effective for Emotion Regulation: DBT helps individuals manage intense emotions and
reduce emotional reactivity through structured skills training.
2. Reduces Self-Destructive Behaviors: It is especially effective for reducing self-harm,
suicidal behaviors, and impulsivity, particularly in individuals with borderline
personality disorder.
3. Teaches Practical Coping Skills: DBT provides concrete tools like mindfulness, distress
tolerance, emotion regulation, and interpersonal effectiveness for real-life challenges.
4. Improves Relationships: Through the interpersonal effectiveness module, individuals
learn to communicate assertively and maintain healthy boundaries.
5. Structured and Supportive Approach: DBT combines individual therapy, group skills
training, and phone coaching, offering consistent support and accountability.
Dis-advantages Of DBT
1. Time-Intensive: DBT typically requires a long-term commitment, including weekly
individual therapy, group sessions, and homework, which can be demanding for clients.
2. Limited Accessibility: Trained DBT therapists and full DBT programs may not be
available in all areas, especially in rural or under-resourced settings.
3. Not Suitable for All Disorders: While effective for borderline personality disorder and
emotional dysregulation, DBT may be less effective or unnecessary for other conditions
like psychosis or mild depression.
4. Requires High Motivation: DBT demands active participation and willingness to
change, which may be difficult for some individuals, especially those in early stages of
therapy.
5. Costly: Full DBT programs can be expensive, especially when including individual
sessions, group therapy, and phone coaching, and are not always fully covered by
insurance.
Results
➤ Several studies evaluating the effect of DBT for patients with BPD found that such therapy was positive.(on
individuals with BPD. The results have been consistently positive, meaning DBT effectively reduces symptoms
and improves functioning in this population).
➤ Patients had a low dropout rate from treatment(Many patients who start DBT tend to stay in therapy rather than
dropping out. This shows that DBT is engaging and manageable, even for those with severe emotional
difficulties, which is a strong indicator of its effectiveness and tolerability).
➤ The incidence of parasuicidal behaviors declined(Parasuicidal behaviors refer to non-lethal, self-harming
actions like cutting, burning, or overdose attempts that aren't always intended to cause death. DBT has been
shown to significantly reduce these behaviors by teaching patients safer coping mechanisms).
➤ Self-report of angry affect decreased(Patients reported feeling less angry and emotionally reactive after
participating in DBT. This suggests improved emotional regulation, one of the core skills taught in DBТ).
➤ Social adjustment and work performance improved(Patients undergoing DBT often show better social
adjustment (e.g., healthier relationships) and improved work performance (e.g., better focus, reduced conflict at
work), reflecting overall functional improvement in daily life.
Reference
Kaplan and Sadock's Synopsis of Psychiatry, 11th Edition
Kaplan and Sadock's Comprehensive textbook of psychiatry, 10th
Edition
