Originally developed by Marsha Linehan, PhD, a Professor of Psychology at the University of Washington and a practitioner of Zen, Dialectical Behavior Therapy (DBT) is a system of therapy that combines elements of Western Psychology, especially Cognitive Behavioral Therapy (CBT), with Eastern mindfulness meditation. DBT was originally created to treat therapy-resistant clients diagnosed with borderline personality disorder (BPD) and was the first therapy to demonstrate evidenced-based effectiveness with this clientele. (Linehan MM, Heard H, Armstrong HE (1994). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Arch Gen Psychiatry 51(5): 422.)
Subsequent research has shown DBT to be effective with a number of other clinical issues, including mood disorders, suicidality, the effects of sexual abuse, and addictions. (See literature resources listed below.)
OVERVIEW OF DBT AND BPD
DBT was designed based on Dr. Linehan’s theory of BPD that depicts the client’s symptoms of BPD as developing from an inherited systemic emotional vulnerability as well as growing up in an emotionally invalidating environment. Physiologically she portrays the BPD client as having an autonomic nervous system response to low levels of stress that is both initially excessive and then slow to return to base levels once the stressor is no longer present.
For Linehan, an emotionally invalidating environment has several characteristics. First, the primary caregivers undermine the child’s own emotional experiences and attempts to express them. The message the child receives is essentially that “You’re not really feeling the way you say you are and even if you were feeling that way, it’s not an appropriate emotional response to the situation.” Secondly in such an environment, there is a high expectation of self-control and self-reliance. When the child fails to live up to this standard, they get the message that they lack motivation, or have some other character flaw.
According to Linehan, a child with a vulnerable autonomic response system raised in such an invalidating environment will have difficulty identifying and expressing their own emotions, looking instead to others for indications of appropriate responses. The child’s behavior will likely alternate between internalization of emotions in order to fit in and strong externalizations that are attempts to have their emotions acknowledged. This ultimately results in a failure to learn how to understand and manage feelings. The absence of this skill in the context of a biological tendency to overreact to stress results in the characteristic symptoms of BPD listed in the DSM-IV-TR: fear of abandonment, unstable relationships, unstable self-image, self-endangering impulsive behavior, self-mutilation or suicidality, unstable mood swings, feelings of emptiness, out-of-control anger, and paranoia.
According to Linehan, the adult borderline client often presents with several pairs of dialectically-opposed behaviors. They tend to blame others for their problems while at the same time invalidating themselves with shame or self-blame for their failure to solve those same problems. Due to their underlying emotional vulnerability, they experience their lives as a series of frequent traumatic events, yet are unable to effectively process the emotions such traumas evoke, especially those involving loss, leading to internalized, unresolved grief. Thirdly, they actively recruit others to solve their problems for them, showing little actual effort themselves to solve their own problems, while at the same time they are good at giving others the impression that they are capable and competent.
THE DBT THERAPEUTIC APPROACH
The general approach of DBT is to resolve these dialectically-opposed behaviors that cause BPD clients and their therapists so much difficulty. From a therapist’s perspective, the dichotomy is that of accepting the client as they are while paradoxically motivating and supporting change. The challenge for the therapist is to embody these seemingly opposing therapeutic strategies. As therapy progresses the dialectical stance of the therapist also includes both firmness and flexibility, as appropriate, while being nurturing, on the one hand, yet demanding, in an empathic and compassionate manner, on the other.
Another hallmark of DBT is the clear focus on the client’s present behavior and
current factors affecting that behavior. The inclusion of mindfulness training for both the therapist and client in DBT strongly supports this therapeutic orientation. Mindfulness is taught to the client not in the therapy session proper but in the context of a four-part skills training group, led by a clinician other than the client’s individual therapist, that runs concurrently with the one-on-one psychotherapy sessions. In addition to basic mindfulness practices, clients learn interpersonal effectiveness skills, emotional modulation techniques, and ways to strengthen their tolerance for distressing experiences.
In addition to individual therapy sessions and skills training groups, two other requisite elements are important in the DBT therapeutic process. The third element is the therapist’s availability to the client by phone, within limits set by the therapist, not for therapy, but to assist the client in the application of skills in real life situations, to help the client avoid self injury, or for the client to repair wounds to their relationship with the therapist before the next session. Lastly, therapists are required to participate in regular consultation sessions where they practice DBT on each other.
As such DBT constitutes a team approach to psychotherapy. The rationale for team-based treatment is to address the tendency of clients diagnosed with BPD to present with suicidality, self-injurious behaviors, and frustrated therapy relationships. Individual therapists who treat such clients can lose their balance easily, either by being too accepting of clients’ problem behaviors or becoming too demanding of the changes their clients need to make. A team approach guards against these tendencies.
Mindfulness is taught as an essential skill in DBT in a manner that is devoid of Buddhist language or beliefs. No religious affiliation is required. Rather mindfulness is developed as a psychological skill for its ability to help the client (and the therapist) develop greater awareness and clarity of their present moment experience and the capacity to stay with the experience of the present even when it is difficult.
However it is interesting to note that the dialectical nature of DBT, the strategy of finding a synthesis between the thesis and antithesis both living within the client, bears significant resemblance to the Buddhist philosophy of the finding the Middle Path between two extremes. A recently published autobiographical account of the struggles of a young woman suffering from BPD, The Buddha & the Borderline: My Recovery From Borderline Personality Disorder Through Dialectical Behavior Therapy, Buddhism, and On-line Dating, by Kiera Van Gelder, draws on this theme.
“I expected to get a somber account of a transformation from suffering to enlightenment, but the book I read was not only entirely entertaining and revealing, but also had me up way past my bedtime in stitches…The book embodies the Four Noble Truths of Buddhism and integrates the world of core unrelenting suffering with the world of freedom from suffering. Transcendent stuff.” from a review of The Buddha and the Borderline by Blaise Aguirre, MD, Medical Director of the Adolescent Dialectical Behavior Therapy Residential Program at McLean Hospital in Belmont, MA.
The following is a video of lecture by Kiera at 2008 National Education Alliance for Borderline Personality Disorder conference sponsored by the Yale University School of Medicine, Department of Psychiatry
For a delightful presentation on DBT, see the following 5-part YouTube VDO series of a lecture by Dr. Linehan, in which she describes the history of DBT, the role of mindfulness meditation in DBT, as well an experiential demonstration of how DBT clients are introduced to mindfulness. (Each segment is 3-6 minutes long.)
For an engaging and informative popular media article on DBT and Dr. Linehan’s work, see Cloud, J (2009). “The Mystery of Borderline Personality Disorder,” TIME Magazine, Jan 8. You can also hear an interview of Dr. Linehan by Dr. Van Nuys on Wise Counsel Podcasts.
Dr. Linehan founded Behavioral Tech, LLC to train mental health care providers and treatment teams who work with complex and severely disordered populations to use compassionate, scientifically valid treatments and to implement and evaluate these treatments in their practice setting. Behavioral Tech offers a range of trainings from introductory classes to 10-day intensives for individuals and for treatment teams interested in learning DBT.
Trainings in DBT maintain a strong focus on the development and practice of trainees’ mindfulness skills. The practice of mindfulness, according to Behavioral Tech’s website, is characterized by
‘allowing’ experiences rather than suppressing or avoiding them. Mindfulness in its totality has to do with the quality of awareness that a person brings to everyday living: learning to control your mind, rather than letting your mind control you. Mindfulness as a practice directs your attention to only one thing, and that one thing is the moment you are living in. When you recognize the moment, what it looks like, feels like, tastes like, sounds like – you are being mindful. Further, mindfulness is the process of observing, describing, and participating in reality in a non-judgmental manner, in the moment and with effectiveness. At the same time, mindfulness is the window to acceptance, freedom, and wisdom. Behavioral Tech, LLC
In the DBT therapeutic process, these skills are invaluable for both for the client and the therapist.
Dr. Linehan has approved a number of experienced trainers and consultants of DBT in the United States and abroad as listed on Behavioral Tech Research, LLC. Their stated mission is to “disseminate scientifically validated behavioral therapies and evidence-based practices.” More information about them and their trainings can be found on the Behavioral Tech website.
While she acknowledges that her theory of BPD is still in need of more empirical verification, Dr. Linehan points out that the theory behind a treatment modality need not be proven if the treatment itself has been shown to be efficacious, as is the case with DBT. Below are links to the extensive research now available on DBT, both as a treatment for BPD and for other mental health issues. Dr. Linehan’s current research projects include a National Institute of Health grant (2008-2013) to develop a curriculum for the training of DBT clinician-scientists.
All of Marsha Linehan’s publications in PubMed.
All of the research on “Dialectic Behavior Therapy” on PubMed.
Linehan M (1993). Skills training manual for treating borderline personality disorder. New York: The Guilford Press.
Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press.
Kiehn B, Swales M (2002). An overview of Dialectical Behaviour Therapy in the treatment of Borderline Personality Disorder updated Jan. 2. www.MentalHelp.net.
Deangelis T (2009). Fostering Lives Worth Living. Monitor on Psychology, April, 2009.