Dialectical Behavior Therapy

Description of the Strategy

Dialectical behavior therapy (DBT) is a comprehensive, multimodal treatment that blends psychotherapy change strategies drawn from cognitive-behavioral approaches with acceptance-based strategies drawn from Eastern meditative (primarily Zen) and Western contemplative practices. These apparently opposing notions, change and acceptance, are integrated within a dialectical framework that guides treatment from case conceptualization to execution of treatment strategies. During the 1980s, Marsha Linehan developed DBT at the University of Washington after finding that [Page 257]standard behavior therapies did not seem effective with the chronically suicidal women she was treating. Linehan, therefore, incorporated a series of acceptance strategies to the treatment together with a set of dialectical strategies aimed at synthesizing the two polarities. DBT later evolved into a treatment for parasuicidal behavior (including both suicide attempts and intentional self-injury) in borderline personality disorder (BPD) and has since been adapted to treat other multidiagnostic, difficult-to-treat populations.

DBT is based on a biosocial theory of the etiology and maintenance of BPD that was developed in an effort to explain BPD criterion characteristics in a manner that is compatible with behavioral theory and consistent with empirical research. The biosocial theory posits that BPD arises from a central dysfunction in the emotion regulation system that develops in childhood as the result of a dynamic transaction between an emotionally vulnerable child and an invalidating environment. The emotional vulnerability is biologically based and manifests as a high sensitivity to emotional stimuli (i.e., lower threshold for emotional response), a high reactivity to emotional stimuli (i.e., stronger emotional response to emotional stimuli), and a slow return to baseline when emotionally aroused (i.e., emotional arousal is long-lasting). People in the child's environment, whether knowingly or unwittingly, invalidate the emotional experience of the child. This, in turn, leads to an escalation of the child's emotional responses or behaviors that attempt to modulate emotions, which can exacerbate the environment's invalidating responses. The biosocial theory maintains that the relationship between the child and the environment is bidirectional and therefore both continuously influence the escalation and deescalation of borderline behaviors.

Accordingly, BPD behaviors are viewed as both the inevitable behavioral outcomes of dysregulated emotions and their display (e.g., changing and unpredictable affective reactions to others or work tasks), as well as maladaptive attempts to regulate emotions (e.g., dropping out of school, promiscuous sex, suicide attempts, etc.). The theory leads to a model of BPD that postulates that (a) BPD individuals lack important interpersonal, self-regulation (including emotion regulation), and distress tolerance skills and (b) characteristics of both the individual and the environment inhibit capabilities that the individual does have and prevent the development of new skills and capabilities. It is therefore essential for the treatment to teach new skills, enhance the skills and capabilities the client already possesses, and improve the client's motivation to use skillful behavior.

As its name suggests, dialectical philosophy is central to DBT. A dialectical framework considers reality as continuous, dynamic, and holistic. Reality, from this perspective, is simultaneously both whole and consisting of bipolar opposites (e.g., atoms consisting of opposing positive and negative charges). Dialectical truth emerges by the process of combination (or synthesis) of elements from both opposing positions (the thesis and antithesis). The primary dialectic in DBT is that of acceptance and change. A therapist may validate clients' perceptions that they are working as hard as they can and yet stress that at the same time, they must work even harder in order to move past their suffering. The acceptance-change balance is modeled both in the treatment strategies of DBT as well as the behavioral skills taught in DBT, with change-based skills such as emotion regulation and interpersonal effectiveness being balanced by more acceptance-based skills such as mindfulness and distress tolerance. From a dialectical perspective, learning to accept is a change in itself, and working to change includes an acceptance of current capabilities.

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