What is Dialectical Behavior Therapy?

A Bit of an Intro to DBT

DBT stands for Dialectical Behavior Therapy. It is a therapy, it’s a behavior therapy, which means we’re going to target behaviors (and cognitions!) in order to affect how you’re feeling, and the nuance that DBT adds over other CBTs is the idea of dialectics. Dialectics is a type of philosophy with a few different components to it, and the important part about it to remember is that there are always multiple truths. There is always more than one way to look at something, in this world. Of course, Hashem is one, Hashem echad. And He created this world with the word “bereishis”, with the letter “beis”, this world signifies multiplicity. This is important because it helps us to see the grays rather than getting stuck in the black and white.

Our most important dialectic in DBT is acceptance and change. Behavior therapy prior to DBT was completely change focused and when Marsha Linehan, PhD, began offering her treatment to women with chronic suicidality, she found that they pushed back, saying “hey, you are not understanding how hard my life is, and you’re expecting me to just change.” She then switched to a Rogerian, person-centered approach focused on acceptance and validation, only to receive further pushback, “my life is a disaster, I need you to stop validating me and actually help me fix it.” This led her to adding a dialectical approach that balances both acceptance and change strategies across treatment. The overarching goal of DBT is to help clients build a life worth living.

The skills we cover in treatment are balanced by acceptance and change skills. Our acceptance skills are mindfulness and distress tolerance. Our change skills are emotion regulation and interpersonal effectiveness. For the adolescent adaptation, we add the walking the middle path skills which are about learning to manage family conflict - these are dialectical strategies. While many people think of DBT as a treatment about skills, skills are really only part of a nuanced and complex treatment model. There are 4 modes of treatment in comprehensive DBT: (1) individual DBT which is a certain style of doing individual therapy involving diary cards and chain analyses of target behaviors to learn patterns and make sure therapy addresses those patterns (family or parenting sessions are often included as well, as needed), (2) DBT skills group where clients learn skills, (3) phone coaching which helps with generalization of the things learned in individual and group, and (4) consultation team for the therapist so the therapist keeps being an awesome DBT therapist. Without all 4 modes, it’s not full DBT. Skills alone can be a helpful adjunct to treatment for some people, and for people who need full DBT, skills alone is not recommended.

DBT treatment is structured in stages, like a House of Treatment. Stage 0 is about orientation and commitment. Clients get oriented to what DBT is and then decide if they would like to commit. Therapists have strategies that they use to help their clients commit, and ultimately, a client who isn't committed, will not move to stage 1. Stage 1 is what people typically think of as DBT. It's about getting in control of ineffective behaviors. In stage 1, we target any life-threatening behaviors, therapy-interfering behaviors, quality-of-life interfering behaviors, and work to increase behavioral skills. Usually after about 6 months to a year, although some people spend more or less time in stage 1, clients are ready for stage 2. In stage 2, we work on getting in touch with emotional experiencing. Clients in this stage may feel they are in quiet desperation. We aim to increase emotional experiencing, reduce emotional avoidance, increase skills, reduce suffering, and treat any PTSD. In stage 3, we work on problems in living and ordinary happiness and unhappiness. We aim to increase self-respect and values-based action and work toward life goals. Most clients don't stick around for stage 4, and stage 4 is about incompleteness, maximizing one's capacity for joy and freedom, spiritual fulfillment, and peak experiencing and flow.

While DBT was originally developed for individuals with BPD, there is now considerable evidence to consider it effective for a wide range of disorders. The core issue is typically emotion dysregulation, across ages and disorders. Adolescents who benefit from DBT typically present with multiple problems (e.g., panic attacks, depression, school refusal, eating disorder, conflict at home, etc.). Children usually carry multiple diagnoses, often, ODD and ADHD or, more accurately, DMDD. Whatever the diagnosis, their symptoms are driven by emotion dysregulation, not callousness function. Emotion dysregulation means difficulty managing, controlling, and influencing emotions. For people who struggle with emotion dysregulation, DBT can be a complete life-changer.