Dialectical Behavior Therapy; What and Why
“My main goal for people who come into therapy is that they get out of hell. That’s my first goal and my second goal is that they stay out of hell. This is why we teach skills because skills are aimed at helping individuals build a life that is worth living.”
Dialectical behavior therapy (DBT) is a variant of cognitive behavior therapy that integrates knowledge from behavior therapy, cognitive therapy, and learning theory as well as dialectical and oriental philosophy (zen). DBT is a principle-driven, partly manual-based treatment model developed in the United States by Professor Marsha Linehan at the University of Washington, Seattle. DBT was designed to meet the need for an efficient treatment method for people with chronic suicidality and borderline personality disorder (BPD). Frequent suicidal crises and continuing self-harm are common in BPD. DBT is considered the gold standard today among treatments for this patient group, and it has also proven to be efficient when dealing with other mental problems.
What Do We Believe in DBT?
“You are doing your best! And you have to work even harder!”
DBT is based on a biosocial understanding of how people may fail to develop an ability to regulate their own feelings. By this we mean difficulties with self-regulation in various situations. Many experience strong mood swings, chaotic relationships, difficulties with their sense of self, a feeling of emptiness, impulsive behavior, and self-harm, as well as at times insufficient cognitive regulation (dissociation / paranoid thoughts). In DBT we understand this deficiency as both biologically and socially conditional. Let us look more closely at why:
We think that we are born with varying degrees of emotional vulnerabilities that give us different outsets with which we experience the world. High emotional vulnerability often involves high sensitivity, high reactivity, and slow return to a calmer emotional state. The term high sensitivity means that the threshold for reaction is low and that the response is often immediate. High reactivity is that the emotional response can become more extreme, and that it is difficult to choose thought-through actions when feelings are intense. In addition, people with high emotional vulnerability usually need more time to return to a calmer emotional state so that they are also more vulnerable in new situations.
We think, too, that our social environment and the experiences we have with us from our childhoods are decisive to how well we can understand our own emotional responses, and how we manage to regulate these efficiently. DBT believes that many people have experienced an invalidating environment, meaning that they have been met with rejection from their environment, regardless of whether the reaction was suitable or understandable. This could entail that they will fail to deal with intense emotional responses.
What Are the Aspects of DBT?
“Clients have to do better, try harder, and be more motivated for change.”
In its original form, DBT treatment is composed of four core components:
DBT Skills Training Group assumes that all people who struggle with regulating their emotions need to learn different skills that may help them become more efficient problem-solvers. The group meets once a week for about two hours, and the lessons are led by one or more group leaders who teach and model skills and give homework that the clients practice during the week. Each complete training period lasts for 24 weeks and is repeated once with 24 more weeks for adults. The lessons revolve around four main topics: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
DBT Individual Therapy focuses on generalizing skills and strengthening the person’s ability to cope with difficult situations more effectively. Individual therapy equals one treatment hour per week and follows the progression of the group sessions.
DBT telephone coaching is a service that the individual therapists offer their clients so that the clients can contact their therapist when needed for quick and direct reinforcement of skills on a day-to-day basis.
The DBT Consultation Team consists of the people who provide DBT, and its focus is on supporting each other to keep up the motivation, to increase the team’s use of skills, and to strengthen professional expertise so that the team can perform their best when using the method during treatment sessions. There are weekly team meetings before the skills training group meetings.
What Are Skills?
“You might not be the root of all your problems, but you have to solve them yourself!”
The core assumption in DBT is that people with Borderline Personality Disorder lack central skills in regulating emotions, behavior, and interpersonal relations, as well as distress tolerance skills. An important focus in DBT is to strengthen the client’s ability to cope in challenging situations through skills training. Mindfulness skills refer to a practice of learning to be fully present in the moment in a non-judgmental, accepting manner. Linehan’s method is considered groundbreaking for how it integrates mindfulness in structured therapy. Mindfulness is a recurrent theme during the whole course of the skills training period. Distress tolerance skills demonstrate possibilities for tolerating pain in difficult situations without having to change the situation. Interpersonal effectiveness skills show how clients may learn to ask for what they need at the same time as they maintain their self-respect and create healthy relationships to others. Emotion regulation skills include how to recognize, understand, and possibly change feelings.
Research on DBT show that skills training is an effective intervention (Linehan et al., 2015; Neacsiu, Rizvi, & Linehan, 2010).
What Does Dialectic Mean? A both/and perspective of the treatment
Dialectics often implies the integration of two opposites and refers to the need to balance different parts of reality at once. In short, dialectics advertises a both/and perspective instead of an either/or perspective. The primary dialectic in DBT is the apparent opposition between strategies for acceptance and strategies for change. Therapists must be able to accept the clients as they are, at the same time as they recognize the clients’ need for change in their lives to reach their goals. All skills and strategies used in DBT aim at this balance between acceptance and change. Mindfulness and distress tolerance skills focus on acceptance-oriented strategies, while emotion regulation and interpersonal skills focus on change-oriented strategies.
Why Choose DBT?
“Life of an emotionally unstable person threatened by suicide is insufferable as such.”
Describing DBT as the gold standard for BPD treatments is based onseveral scientific studies. DBT is, due to strong research-based evidence, validated by several important institutions as an effective method. In the NICE guidelines that name evidence-based treatments in Great Britain, DBT is mentioned as the only recommended specialized treatment method for BPD (NICE, 2009), and it is described in SAMHSA’s (U.S. Substance Abuse and Mental Health Service Administration) National Register for Evidence-based Programs and Practices as “one of the best, if not the best, treatments for BPD”, (SAMHSA, 2011). The American Psychological Association’s Society of Clinical Psychology considers DBT to be the only form of therapy available today that qualifies as Level 1 (highest level) for its evidence (APA Division 12, 2012). Also, Cochrane Database of Systematic Reviews (considered the most esteemed academic community for assessing scientific data) concludes that DBT is effective at reducing anger and self-harm and generally improving daily functioning (Stoffers et al., 2012).
DBT’s evidence base is comprehensive, and research is ongoing for both the original model as well as for new adjustments. So far, 32 randomized control trials at 20 independent institutions in 8 different counties with 12 different patient populations have demonstrated a statistically significant improvement for DBT clients. Effect studies have shown that DBT significantly reduces suicidal behavior, self-harm, need for admission at emergency wards or emergency rooms, therapy dropout rates, drug abuse, anger, depression, as well as improves general functioning for social and global goals. No other treatment method has such comprehensive evidence for the patient group with BPD. At the National Centre for Suicide Research (NSSF), DBT has proven effective in treatment of adolescents who self-harm, and our research suggests that the positive outcomes are sustained after treatment (Mehlum et al., 2016; Mehlum et al., 2014; Tormoen et al., 2014). The model has proven effective in treating a number of mental illnesses tied to emotion regulation problems, such as drug addiction, overeating disorders, and depression, as well as in treating people with coexisting difficulties within BPD and post-traumatic symptoms.
DBT was originally developed for treatment at polyclinics, but has later been adapted to treatment at inpatient facilities as well as for different age groups. The method has spread all over the world, and today there are over 20 specialized teams in Norway using DBT for both children and adolescents, and adults.
DBT in Norway
The clinical research group at the National Centre for Suicide Research and Prevention (NSSF) has conducted one of the few randomized control trials on DBT treatment for adolescents who self-harm. The education program in DBT was launched in 2006 and educated the first research therapists who would include patients for our studies. NSSF has since given introductory courses to numerous clinicians in Norway, Denmark, and Finland.
Our teachers and supervisors offer clinical supervision to DBT teams within both adult and pediatric psychiatry, as well as within the drug and addiction field. The DBT program at NSSF has trained more than 300 DBT therapists since 2006. The educational program is one of the few worldwide that is directly certified by the Linehan Institute as an independent international collaborator. Our Norwegian teachers have been trained directly by the educational unit at the Linehan Institute, and they are certified for running a fully satisfactory course in the method, both for therapists and others who will teach DBT. Thus, our center has a solid role as the only provider of the intensive training and supervision in DBT in Norway.
Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., . . . Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. JAMA Psychiatry, 72(5), 475-482. doi:10.1001/jamapsychiatry.2014.3039
Mehlum, L., Ramberg, M., Tørmoen, A. J., Haga, E., Diep, L. M., Stanley, B. H., . . . Grøholt, B. (2016). Dialectical Behavior Therapy Compared With Enhanced Usual Care for Adolescents With Repeated Suicidal and Self-Harming Behavior: Outcomes Over a One-Year Follow-Up. Journal of the American Academy of Child & Adolescent Psychiatry, 55(4), 295-300. doi:10.1016/j.jaac.2016.01.005
Mehlum, L., Tormoen, A. J., Ramberg, M., Haga, E., Diep, L. M., Laberg, S., . . . Groholt, B. (2014). Dialectical Behavior Therapy for Adolescents With Repeated Suicidal and Self-harming Behavior: A Randomized Trial. J Am. Acad. Child Adolesc. Psychiatry, 53(10), 1082-1091. doi:S0890-8567(14)00499-7 [pii];10.1016/j.jaac.2014.07.003 [doi]
Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behav. Res. Ther, 48(9), 832-839. doi:S0005-7967(10)00113-0 [pii];10.1016/j.brat.2010.05.017 [doi]
Tormoen, A. J., Groholt, B., Haga, E., Brager-Larsen, A., Miller, A., Walby, F., . . . Mehlum, L. (2014). Feasibility of Dialectical Behavior Therapy with Suicidal and Self-Harming Adolescents with Multi-Problems: Training, Adherence and Retention. Arch Suicide Res. doi:10.1080/13811118.2013.826156 [doi]