WHAT IS DIALECTICAL BEHAVIOR THERAPY?

Dialectical Behavior Therapy (DBT) is a treatment designed specifically for individuals with self-harm behaviors, such as self-cutting, suicide thoughts, urges to suicide, and suicide attempts. Many clients with these behaviors meet criteria for a disorder called borderline personality (BPD). It is not unusual for individuals diagnosed with BPD to also struggle with other problems -- depression, bipolar disorder, and post-traumatic stress disorder (PTSD), anxiety, eating disorders, or alcohol and drug problems. DBT is a modification of cognitive behavioral therapy (CBT). In developing DBT, Marsha Linehan, Ph.D. (1993a) first tried applying standard CBT to people who engaged in self-injury, made suicide attempts, and struggled with out-of-control emotions. When CBT did not work as well as she thought it would, Dr. Linehan and her research team added other types of techniques until they developed a treatment that worked better. We'll go into more detail about these techniques below, but it's important to note that DBT is an "empirically-supported treatment." That means it has been researched in clinical trials, just as new medications should be researched to determine whether or not they work better than a placebo (sugar pill). While the research on DBT was conducted initially with women who were diagnosed with BPD, DBT is now being used for women who binge eat, teenagers who are depressed and suicidal, and older clients who become depressed again and again. 

WHAT ARE THE THREE FUNDAMENTALS OF DBT?

The three fundamentals of DBT: CBT, Acceptance, and Dialectics
1) Cognitive Behavioral Therapy
 CBT and DBT therapists do not think that clients can be helped through insightful discussions, although insight can be helpful at times. Learning new behaviors is critical in DBT and is a focus in every individual session, skills group or phone call (for coaching). "Behavior" refers to anything a person thinks, feels, or does. Cognitive behavioral therapy uses a wide variety of techniques to help people change behaviors that inhibit a "life worth living." In DBT, as in CBT, clients are asked to change. Clients track and record their problem behaviors with a weekly diary card. They also attend skills groups, complete homework assignments and role-play new ways of interacting with people when in session with their therapist. In addition, clients work with their therapist to identify how they are rewarded for maladaptive behavior or punished for adaptive behavior. They expose themselves to feelings, thoughts or situations that they feared and avoided, and they change self-destructive ways of thinking. What we have just described in layman's terms are the four main change strategies: Skills Training, Exposure Therapy, Cognitive Therapy, and Contingency Management. 

A great book on one main technique in behavior therapy - contingency management - is Karen Pryor's Don't Shoot the Dog (Bantam Books). Karen Pryor is a dolphin trainer who opened Hawaii's first ocean park. The principles an animal behaviorist like Pryor uses to teach animals are the same principles we can use with ourselves to change ourselves and make our relationships better. Karen Pryor's book is fun, humane, and easy to understand. Contrary to popular belief, behavior therapy is not cold and technical. Rather, at its best, it is about learning to change while treating ourselves and each other with respect and kindness. If you read this book (and it can be read in an evening), you'll know a lot more about how one of the main strategies cognitive behavioral therapy works. You can also take a lot of the techniques and apply them to your life at home, work, or school.

2) Validation (Acceptance) As we noted in the above paragraphs, cognitive behavioral therapy techniques were not enough to help clients who were suicidal and chronically self-harming in the context of Borderline Personality Disorder (BPD). It's not that the techniques were ineffective; it's just that as stand-alone interventions, they caused clients a great deal of distress. Clients found the pushing for change invalidating. In a simple example, it's as if therapists were saying to someone with severe burns on the soles of their feet, "just keep walking and your feet will get stronger…try not to think about the pain," though each step was excruciatingly painful, and the patient was depressed and had no experience with keeping her mind off severe pain. 

Linehan and her research team discovered that when the therapist weaved an emphasis on validation with an equal emphasis on change, clients were more likely to be collaborative and less likely to become agitated and withdrawn. So what is validation? It means a number of things. One of the things it does not mean, necessarily, is agreement. For instance, a therapist could understand that a client abuses alcohol to overcome intensive social anxiety, and yet realize that when the client is drunk, he makes impulsive decisions that may lead to self-harm. The therapist could validate that: a) her behavior makes sense as the only way she's ever gotten her anxiety to go down; b) her parents always got drunk at parties; and c) sometimes when she's drunk and does something impulsive, the impulsive behavior can be "fun." In this case, the therapist can validate that the substance abuse makes sense, given the client’s history and point of view. But the therapist does not have to agree that abusing alcohol is the best approach to solving the client's anxiety. 

In DBT, there are several levels and types of validation. The most basic level is staying alert to the other person. This means being respectful to what she is saying, feeling, and doing. Other levels of validation involve helping the client regain confidence both by assuming that her behavior makes perfect sense (e.g. of course you’re angry at the store manager because he tried to overcharge you and then lied about it) and by treating the other person as an equal (i.e., as opposed to treating her like a fragile mental patient). 

In DBT, just as clients are taught to use cognitive behavioral strategies, they are also taught and encouraged to use validation. In treatment and in life, it is important to know what about ourselves we can change and what about ourselves we must accept (whether short term or the long term). For that reason, acceptance and validation skills are taught in the skills modules as well. 

There are four skills modules all together - two emphasize change and two emphasize acceptance. For example, it is extremely important that clients who self-harm learn to accept the experience of pain instead of turning to self-destructive behavior to solve their problems. Likewise, clients who cut themselves, binge and purge, abuse alcohol and drugs, dissociate, etc., must learn to simply "be with" reality, as painful as it may be at any given moment, in order to learn that they "can stand it." DBT teaches a host of skills so that clients can learn to stand still instead of running away. DBT also teaches clients how to work to understand why their lives are so hard. 

3) Dialectics
"Dialectics" is a complex concept that has its roots in philosophy and science. We won't go into its background here but we will attempt to explain what we mean by dialectics and give examples of thinking dialectically. "Dialectics" involves several assumptions about the nature of reality: 1) everything is connected to everything else; 2) change is constant and inevitable; and 3) opposites can be integrated to form a closer approximation to the truth (which is always evolving). Here's a brief example about how these assumptions would come into play in a DBT program. Suppose you are silent in groups. The other group members are affected by your silence and they try to get you to talk. You affect them and they affect you. Perhaps the group pushes you so hard that you feel like quitting and you talk even less. Then the other members get tired of your silence and withdraw. Paradoxically, this makes you feel better and causes you to talk a bit more. As you become a true member of the group, the leaders shift the way they run the group in order to manage the tension between you and the other members. In other words, you are all interconnected, influencing each other in each moment. 

As time passes in the group, there are inevitable changes. Perhaps the group becomes more skilled at getting you to talk. Perhaps you take some risks and talk more. Maybe a new member enters the group while an older member of the community transitions out and the group struggles to adjust to the new arrangement. You also may become aware that your thoughts and feelings change throughout the group, as does every other group member's. You notice that the group is constantly evolving, constantly readjusting itself. Thinking dialectically means recognizing that all points of view-yours, the other members - have validity and yet all may also be wrong-headed at the same time. If the group is working together dialectically, the group leaders and the members are in constant flux, looking at how opposing points of view can be in play and yet be synthesized. In short, the group is always balancing change and acceptance. Throughout, the group leader and the members would try to hold on to the idea that everyone is doing the best he or she can AND that everyone has got to do better. 

DBT also involves specific dialectical strategies to help clients get "unstuck" from rigid ways of thinking or viewing the world. Some of these are traditional Western therapy interventions and others draw on Eastern ways of viewing life. If you read Linehan's (1993a) text, you can read about these strategies in chapter seven and review the examples she gives. But here are two examples. Suppose a client makes a strong initial commitment to do a year's worth of DBT. Rather than simply saying "Hey, that's terrific!" the therapist would gently turn the tables on the client by asking, "Are you sure you want to? It's going to be very hard work." This strategy, called "Devil's advocate," causes the client to argue in favor of why and how she will complete the therapy and not drop out. In this case, the therapist guides the client to strengthen her (the client's) arguments for being accepted into treatment, rather than the therapist trying to convince her to stay. "Making Lemonade out of Lemons," another strategy, also helps the clinician handle similarly tough situations. For instance, a client may complain that she absolutely hates her group therapist and wants to switch skills groups. The therapist might respond with an opposing suggestion: This can be seen as a learning opportunity in handling intense negative emotions towards authority. The therapist could then show the similarity between the client's group therapist and other persons of authority (teachers, bosses, supervisors), and demonstrate this as a chance to tolerate a person one can't stand but has to work with. As these examples illustrate, the point of all dialectical strategies is to provide movement, speed, and flow so that therapist and client do not become stuck in "I will not do that" vs. "Oh, yes you will!"