Dialectical Behavioral Therapy
Marsha Linehan (1991) pioneered this treatment, based on the
idea that psychosocial treatment of those with Borderline
Personality Disorder was as important in controlling the condition as
traditional psycho- and pharmacotherapy were. Concomitant with this
belief was a hierarchical structure of treatment goals. Paramount
among these was reducing parasuicidal (self-injuring) and
life-threatening behaviors. Next came reducing behaviors that
interfered the the therapy/treatment process, and finally reducing
behaviors that reduced the client's quality of life. In 1991, Linehan
published results of a study that seems to do remarkably well at
achieving these goals.
The Theory
Basically, DBT maintains that some people, due to invalidating
environments during upbringing and due to biological factors as yet
unknown, react abnormally to emotional stimulation. Their level of
arousal goes up much more quickly, peaks at a higher level, and takes
more time to return to baseline. This explains why borderlines are
known for crisis-strewn lives and extreme emotional lability (emotions
that shift rapidly). Because of their past invalidation, they don't
have any methods for coping with these sudden, intense surges of
emotion. DBT is a method for teaching skills that will help in this
task.
How it works
Dialectical Behavioral Therapy (DBT) consists of two parts:
- Once-weekly psychotherapy sessions in which a particular
problematic behavior or event from the past week is explored in
detail, beginning with the chain of events leading up to it, going
through alternative solutions that might have been used, and examining
what kept the client from using more adaptive solutions to the
problem:
Both between and during sessions, the
therapist actively teaches and reinforces adaptive behaviors,
especially as they occur within the therapeutic relationship. . . the
emphasis is on teaching patients how to manage emotional trauma rather
than reducing or taking them out of crises. . . . Telephone contact
with the individual therapist between sessions is part of DBT
procedures.
(Linehan, 1991)
DBT targets behaviors in a descending hierarchy:
- decreasing high-risk suicidal behaviors
- decreasing responses or behaviors (by either therapist or patient) that
interfere with therapy
- decreasing behaviors that interfere with/reduce quality of life
- decreasing and dealing with post-traumatic stress responses
- enhancing respect for self
- acquisition of the behavioral skills taught in group
- additional goals set by patient
- Weekly 2.5-hour group therapy sessions in which interpersonal
effectiveness, distress tolerance/reality acceptance skills, emotion
regulation, and mindfulness skills are taught (see summaries of sample
worksheets). Group therapists are not
available over the phone between sessions; they refer patients in
crisis to the individual therapist.
Followup studies
Since the 1991 paper, Linehan has been involved in several
replication studies and has written a book and a skills training
manual about DBT. Her results consistently show that DBT does seem to
reduce the amount of self-injury and crisis among clients. (See references.
Linehan's group works out of the University of Washington in Seattle,
but there are DBT-trained therapists in other parts of the U.S. For
information, try contacting the University of Washington Department of
Psychology or go to DBT
Seattle.
There is also a DBT skills discussion list, also at UW. To subscribe,
send mail to the listowner (Kieu) at busserv@u.washington.edu
explaining your background and why you'd like to be on the list. It's
intended to be a place to share experiences and get support while
using dbt skills.
For a comprehensive, scientific review of DBT, see Dialectical
Behavioral Therapy by Barry Kiehn and Michaela Swales of Gwynfa
Adolescent Service in North Wales.
