Psychologist Marsha M. Linehan founded dialectical behavior therapy (DBT) in the late 1980s. DBT was originally developed to treat severe cases of suicidal behavior, usually in individuals with borderline personality disorder (BPD). Having a basic understanding of BPD helps to put DBT into context. The theory underlying DBT reflects the features of BPD. A starting point of DBT is that some individuals are disposed to react in a far more extreme or intense manner to emotional situations and relationships compared to other people. The main characteristics of BPD include emotional swings and volatile personal relationships.
How DBT Developed
In addition to being proven as an effective treatment for BPD and other mental health disorders, DBT appreciates an unexpected layer of approval among recipients. As The New York Times reports, Linehan herself lived with BPD. At the age of 17, Linehan recalls being confined to a room in a psychiatric center reserved for the most extreme cases. At that time, Linehan already had an established history of self-mutilation, including slashing her body and burning cigarette holes into her wrists. Linehan made a recovery years after this hospital admission through what she describes as the power of self-acceptance. Linehan believes that she was an undiagnosed case of BPD. Today, Linehan says that while she was professionally developing DBT, she was essentially, whether she knew it or not, creating the therapy she wished she would have had when she was younger and suffering greatly.
Today, Linehan calls the process she spontaneously underwent years ago as “radical acceptance,” and it’s part of the bedrock of DBT. Linehan believes that her personal healing, through radical acceptance, began when she stopped being angry at herself for feeling that she did not measure up to her parents’ expectations. Linehan, the psychologist, then translated this observation into a psychological theory that people can heal if they accept life as it is – not how they think it is supposed to be – and are willing to make personal changes in the face of that reality. The theory blended well with behaviorism, which was then emerging as a psychological theory that if people learned new healthier behaviors, over time, they could improve their emotions. To put her theory to the test, Linehan began to treat individuals with severe cases of suicidal behavior. Many of these individuals had a BPD diagnosis. In practice with these patients, Linehan helped to guide them to accept the symptoms, such as rage and acute loneliness, they experienced. Next, Linehan would guide these patients to accept that their reactions, such as self-cutting and suicide attempts, made sense in view of their feelings. Finally, Linehan would elicit a commitment to change from these patients. As the method continued to evolve, Linehan added teaching patients day-to-day emotional management skills. Today, all of these therapy components are collected under the theory of DBT.
DBT in Practice
DBT is a type of cognitive behavioral therapy, which means that it addresses and treats both the psychological and behavioral components of mental illness. The term “dialectic” refers to the combination of two separate process; in the case of DBT, that means the opposing forces of change and acceptance. Acceptance is not generally associated with personal change, but in DBT, the former is a necessary step to accomplish the latter.
DBT has two main components. Firstly, the psychotherapist and client meet weekly in one-on-one psychotherapy sessions. A session can center on any number of focus points. There is usually an emphasis on problem-solving. A sample of issues that may be addressed in DBT include:
- Any current self-injury or suicide behaviors
- Ways to decrease stress
- Behaviors that may disrupt therapy
- Addressing any post-traumatic stress
- Quality of life/lifestyle concerns
- Ways to improve self-image and self-respect
- Ways to improve day-to-day living
Secondly, a DBT therapist works with clients in a group setting. In general, these sessions are 2.5 hours and address the four modules. The first module is to build acceptance skills or distress tolerance. This module focuses on how to accept the reality of any given situation in a nonjudgmental way, in part by bringing mindfulness to it (more on mindfulness follows). This approach teaches successful ways to tolerate pain, which is an inevitable part of the human experience. Teachings of this component of DBT include four sets of crisis survival strategies: thinking through pros and cons, self-soothing, how to improve the present moment, and distracting techniques. The second module is interpersonal effectiveness. Strategies of this component include learning how to effectively ask for what one needs, saying “no” to unwanted invitations or opportunities, and learning how to cope with interpersonal conflict. One goal of this component of DBT is to maximize a person’s ability to get what they need from any given relationship without damaging the relationship. Building skills in this area includes working through real life situations in a class or one-on-one setting.
The National Alliance on Mental Illness states that the majority of DBT clients will experience significant long-term periods of symptom remission.
Emotion regulation is a third module involved in DBT treatment. Again, DBT was developed to treat BPD, but it has been shown to be effective in treating other mental health disorders. For disorders other than BPD that feature poor emotional regulation, DBT may be an effective treatment match. Within this module, a DBT therapist will help clients to develop a number of practical skills, such as how to identify and label emotions, reduce the power of the emotions to take over, increase mindfulness of present emotions, and identify those obstacles in the way of changing emotions for improved living. A fourth module is mindfulness. This approach teaches clients the healing power of thought observation as compared to automatic reactions to external events, emotions, and personal relationships. The mindfulness approach posits that a person can take a step back from a thought, emotion, or behavior and witness it in a nonjudgmental light. From that perspective, it is easier to identify the transient nature of thoughts and not overly identify with them. For instance, a thought such as, “I am a disappointment to my family,” need not hold any true sway over a person. There is considerable self-empowerment to be learned from realizing a negative thought is not actually a reflection of reality. A thought is just a thought; it is individuals who give thoughts power, often with negative consequences. Through this greater neutrality individuals can further develop personal traits such as self-compassion.
Self-Compassion in DBT
As discussed, DBT is designed to encourage acceptance and change. Self-compassion can be envisioned as one of the benefits that develop from this process. In other words, a person who successfully practices DBT will develop greater self-compassion in the process. In turn, self-compassion works to promote the entire skillset learned in DBT as well as the willingness to continue therapy. Kristen Neff, PhD, author of Self-Compassion, is responsible for providing treatment professionals and the public with one of the most comprehensive definitions of self-compassion. Set in the wider framework of mindfulness, self-compassion is a quality that naturally arises as part of a shift into a more neutral perspective on thoughts, actions, and emotions. Neff describes self-compassion as having three components: self-kindness, common humanity, and mindfulness.
“A moment of self-compassion can change your entire day. A string of such moments can change the course of your life. – Christopher K. Germer, author of The Mindful Path to Self-Compassion.
Source: Christopher K. Germer
Self-kindness is a necessary balm to soothe a painful experience. A crisis or other difficult situation is a time for a person to step up and care for herself. However, the opposite reaction often happens. In difficult times, many people turn against themselves and are self-critical, judgmental, and even hateful. As self-compassion develops and expands, people who have a pattern of being harsh on themselves can recognize that personal imperfections, unmet expectations, and life difficulties are just part of the human experience.
The development of a strong sense of common humanity is a way to counteract negative thoughts, actions, and emotions that push individuals into isolation. Humanity is the opposite of isolation; even if one is physically separate from others, thinking in terms of common humanity means that we know we are always part of a greater framework. Through self-compassion, a person can shift negative experiences away from her own shoulders and place them in the universal framework of being human.
Mindfulness has been discussed above, but Neff reiterates that the practice of mindfulness is a path to self-compassion. Neff describes mindfulness as a receptive state in which a person is open to experiencing personal transformation. Receptivity can happen when individuals learn to stop focusing on suppressing or denying feelings and learn to accept them. This process involves the wisdom of the adage, “There’s nothing to fear but fear itself.” Mindfulness deflates the power thoughts, actions, and emotions have to control life.
The practice of self-compassion is cultivated in DBT, but it is always advisable for one to work on oneself outside of structured therapy. To that end, World of Psychology provides guidance on how to incorporate self-compassion into daily living. Simple strategies including treating oneself as well as others, noticing one’s language to ensure it’s not judgmental, comforting oneself with a physical gesture such as holding a hand over the heart to calm down, repeating some compassionate phrases (self-help expert Louise Hay provides numerous affirmations), and practicing self-compassion meditation. All of these approaches will complement DBT therapy.
DBT in Substance Abuse Treatment
Research supports that DBT is a successful form of psychotherapy for the treatment of substance abuse and addiction. The emphasis of DBT on acceptance and change is compatible with the philosophy of 12-step programs. In the substance abuse addiction context, DBT can be used as an abstinence strategy. One such strategy is for the therapist to ask the client to commit to stop abusing drugs for a set period of time, which can be as short as five minutes. At the end of the session, the therapist may ask the client to commit to abstinence for another specific period of time. Over numerous sessions, both during and/or after intensive inpatient or outpatient therapy, the client will have a block of time of mental commitment to abstinence. This approach is similar to the 12-step “Just for Today” saying, which rests on a similar psychological strategy to reach the goal of long-term abstinence through moment-to-moment decisions.A therapist may also strongly encourage the client to terminate connections to past drug abuse. For example, the therapist may give specific guidance, such as for the client to broadcast to current drug abusers that he is no longer using drugs, to get a new phone number, and to remove all drug paraphernalia from his surroundings. In this way, the therapist works with the client to remove possible drug cues before they manifest. In terms of drug cues that do arise, DBT teaches clients ways to successfully respond to avoid a relapse.<
DBT not only provides strategies to promote abstinence but also to handle a relapse if it does occur. DBT approaches a relapse as a problem that needs a solution and not a treatment failure. In a DBT session centered on relapse, the therapist may guide the client through a behavioral analysis of the events leading up to the relapse. This information can then be incorporated into future sessions to help the therapist and client develop skills and tools for the client to use if in a state conducive to drug use. At the same time, the therapist may directly address the feelings of guilt or any other emotions associated with the drug relapse. This is an intervention to prevent the client from spiraling into a negative thought pattern, such as, “I blew it, why bother trying?” and then continuing to use drugs. This approach may also include the therapist working with the client to repair the harm caused to himself, any loved ones, or any others during the relapse. This component echoes Step 8 of the 12 Steps: the making of amends to affected individuals.
The ability of DBT to reach deep-set psychological complexes is part of the reason it has succeeded in the treatment of suicidal individuals with or without a BPD diagnosis, substance abusers, and even individuals with a dual diagnosis. A person with a dual diagnosis is one who has been clinically diagnosed with a co-occurring substance use disorder and at least one official mental health disorder. DBT’s compatibility with the 12-step model and incorporation of mindfulness techniques render it part of a family of therapies centered on empowerment of the client so that she may continue to heal herself for a lifetime and maintain sobriety.
 “What is DBT?” (n.d.). The Linehan Institute. Accessed June 23, 2015.  “BPD Overview.” National Education Alliance Borderline Personality Disorder. Accessed June 23, 2015.  Carey, B. (June 23, 2011). “Expert on Mental Illness Reveals Her Own Fight.” New York Times. Accessed June 23, 2015.  Ibid.  Ibid.  “An Overview of Dialectical Behavior Therapy.” (Jan. 30, 2015). PscyhCentral. Accessed June 23, 2015.  Ibid.  Ibid.  Ibid.  Ibid.  Baime, M. (n.d.). “Practicing Mindfulness.” PBS: This Emotional Life. Accessed June 23, 2015.  “Self-Compassion.” (n.d.). Self-Compassion. Accessed June 23, 2015.  Ibid.  Ibid.  Ibid.  Tartakovsky, M. (June 27, 2012). “5 Strategies for Self-Compassion.” World of Psychology. Accessed June 23, 2015.  Dimeff, L. & Linehan, M. (June 2008). “Dialectical Behavior Therapy for Substance Abusers.” Addiction Science Clinical Practice. Accessed June 23, 2015.  Ibid.  Ibid.