Dialectical Behaviour Therapy (DBT)

Dialectical Behaviour Therapy (DBT; Linehan, 1993) is a multimodal cognitive-behavioural treatment for Borderline Personality Disorder (BPD). It is based on a dialectical world-view and biosocial theory of the development of BPD. From the dialectical perspective, reality is comprised of opposing forces, which both contain wisdom but are incomplete without recognition of their interrelatedness and the wholeness of reality. The most fundamental dialectic in DBT emphasizes the tension between a client’s need to accept themselves with their need to make changes. The opposing poles of such dialectic dilemmas continually need to be integrated and synthesized as new opposing forces emerge. DBT therapists attend to this constantly changing tension and strive to balance strategies aimed at increasing acceptance (e.g. validation, mindfulness, radical acceptance) with behavioural interventions aimed at changing self-destructive and ineffective actions (e.g. reinforcing adaptive behaviour, problem solving, behavioural chain analyses, exposure; Linehan, 1993).

Conceptual Model

According to Linehan (1993), BPD is characterised by emotional dysregulation, resulting from the transactional influences between an individual’s biological disposition and an invalidating environment. Individuals with BPD are thought to exhibit emotional vulnerability characterized by a low threshold for emotional responses, intense reactions, and a slow return to their baseline level of functioning. If emotionally vulnerable individuals grow up in environments that are invalidating, they are thought to be particularly at risk for emotional dysregulation, which in turn pulls for further invalidation from others who may struggle to respond to their more intense reactions. Invalidating environments are characterized by a lack of attunement to the individuals’ feelings and thoughts. Caregivers may ignore, trivialize, punish, or attempt to control their child’s feelings. Parents who are generally insensitive may mainly respond if their child’s emotions or behaviour become very intense or destructive, which could reinforce these reactions in the child. A significant proportion of individuals with BPD also report past sexual abuse, which is conceptualized as a traumatic form of extreme invalidation (See section on Traumatic Experiences on the Etiology page). These environments teach individuals to invalidate themselves and fail to show children how to identify what they are feeling, regulate their arousal, tolerate distress, and engage in adaptive problem solving.

Thus, individuals with BPD are thought to experience strong emotional reactions and lack adaptive skills to regulate their distress. The self-destructive and problematic behaviours associated with BPD can be seen as maladaptive attempts to obtain temporary relief from emotional dysregulation. Emotional instability and coping skill deficits are believed to underlie shifts in cognition, unpredictable behaviour, interpersonal problems, and difficulty forming a consistent view of oneself. From a dialectical perspective, this tendency to go to extremes represents being stuck at one pole of a dialectical dilemma. Achieving a more balanced state is thought to require an ongoing synthesis of unacknowledged opposing views.

The Treatment

DBT is a highly structured treatment with specifically defined goals, techniques, and treatment components. DBT focuses on increasing clients’ commitment to treatment goals, reducing dysfunctional behaviour, developing new coping skills, encouraging skill use in everyday life, and structuring the environment so that adaptive behaviours are reinforced (Chapman, 2006).

DBT outlines three stages of treatment: 1) stopping problematic behaviours and increasing behavioural skills, 2) treatment of post traumatic stress and 3) increasing self respect, improving relationships, and working on individual goals. However, individuals with BPD are likely to stay in the first stage of therapy for the first year and most writing and research on DBT focuses on this stage.

In DBT, clients attend an hour of individual therapy once a week. Therapists strive to create a validating context for the therapy, modify their communication style to facilitate change (e.g. use of irreverence to get the client to see things in a new way), encourage dialectical thinking by attending to what is missing from the client’s understanding and integrate opposing views, and use various strategies to encourage acceptance (e.g. mindfulness) or behaviour change (e.g. chain analysis). The focus of the sessions is determined by a hierarchy of treatment targets. The first priority is to decrease any self harm and suicidal behaviours; the second target is to attend to any behaviour that interferes with therapy; the third priority is decreasing behaviours that interfere with the client’s quality of life; and the fourth priority is increasing behavioural skills. Clients also attend two-hour weekly skills training groups, which focus on mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness skills. Clients are able to call their therapist between sessions for telephone coaching to help them to employ their skills in everyday life. Therapists also attend weekly consultation team meetings, which aim to maintain therapist motivation, enhance treatment skills, problem solve, and encourage a non-judgemental stance towards clients. DBT is a long-term treatment, lasting at least one year, and often longer.

Research on DBT

The findings of several randomized controlled trials (RCTs) by independent research teams have supported the efficacy of DBT and determined that it warrants designation as a “well established” treatment for BPD (Linehan, Armstrong, Suarez, Allmon & Heard, 1991; Chambless & Ollendick, 2001).

DBT has outperformed treatment as usual (TAU) on the primary treatment priority of decreasing suicidal and self injurious behaviours in the majority of RCTs (Kliem, Kröger, & Kosfelder, 2010; Koons et al., 2001; Linehan et al., 1991; van den Bosch, Koeter, Stijnen, Verheul, & van, 2005; Verheul et al., 2003). Across studies, DBT was found to have a moderate effect on this outcome (Kliem et al., 2010).

Results are less consistent for other treatment targets. DBT outperformed TAU in improving social functioning and reducing anger (Koons et al., 2001; Linehan et al., 1991; Linehan et al., 1999) and outperformed TAU in reducing substance use and increasing positive and protective feelings towards the self (Linehan et al., 2006). However, DBT and TAU clients showed similar improvement on hopelessness, reasons for living, and dissociation (Koons et al., 2001; Linehan et al., 1991). As well, DBT and TAU resulted in similar treatment gains on anxiety, depression, and eating disorders (Linehan et al., 2006).

DBT has also been compared to other structured treatments: Transference-Focused Psychotherapy (TFP; Clarkin, Levy, Lenzenweger, & Kernberg, 2007) and general psychiatric management consisting of psychodynamic therapy and medication (McMain et al., 2009). On all treatment outcomes (e.g. self harm, symptom distress), DBT and the comparison treatment resulted in similar improvements (Clarkin et al., 2007; McMain et al., 2009).

DBT’s emphasis on commitment to therapy and addressing therapy interfering behaviours does not consistently result in lower dropout rates. A recent meta-analysis indicated that roughly 27.3% of clients stopped attending sessions before the end of the treatment, which is similar to other treatment conditions for BPD (Kliem et al., 2010).

At 12 months post treatment, DBT continues to outperform TAU on some measures (e.g. social functioning, substance use; Linehan, Heard, & Armstrong, 1993; van et al., 2005). However, across studies, overall gains appear to be slightly reduced a year after treatment has ended (Kliem et al., 2010).

DBT remains the most researched structured treatment for BPD. Several research studies support DBT as being superior to treatment as usual in the reduction of suicidal and self-injurious behaviours. It is important to note that these studies have examined a complete multimodal delivery of DBT; the effectiveness of one singular component of DBT is unclear. Furthermore, DBT has not been established as superior to other structured treatments for BPD.