Dialectical Behaviour Therapy, or DBT, was developed in 1993 by U.S. psychologist Marsha Linehan for use specifically with clients diagnosed with Borderline Personality Disorder (BPD), who cope with distressing emotions and situations by using self-destructive behaviours such as suicide and self-harm, eating disorders, and substance abuse. Linehan’s assessment of the therapies available to BPD clients at the time was that traditional treatments were “woefully inadequate” (1993, p 3).

DBT has two decades of research behind it and is considered the “gold standard” for the treatment of Borderline Personality Disorder (Grohol, 2009). Recent research, for example, has shown that DBT is effective at reducing the harmful behaviours that go with BPD diagnosis.

In a randomised controlled study within a routine Australian public mental health service, adult patients with BPD were provided with outpatient DBT for six months with patient outcomes compared to those obtained from patients in a wait list group receiving treatment as usual. After six months, the DBT group showed significantly greater reductions in suicidal and non-suicidal self-injury, emergency department visits, psychiatric admissions and bed days.

On self-report measures, the DBT patients demonstrated significantly improved depression, anxiety and general symptom severity scores compared to the treatment-as-usual group. Average treatment costs were significantly lower for those patients in DBT than those receiving treatment as usual (Pasieczny & Connor, 2011). Providing DBT can be both clinically effective and cost effective.

DBT’s origins: The insight and the hypothesis

If you have worked professionally with populations which have suffered from childhood abuse, particularly sexual abuse, you know the seemingly intractable psychological damage it inflicts on its victims. Moreover, many of them have additionally had to cope with dealing with the trauma in a profoundly invalidating environment.

Linehan hypothesised that it was the combination of an emotionally vulnerable individual growing up in an invalidating environment which produced Borderline Personality Disorder. She defines “emotionally vulnerable” as someone whose autonomic nervous system reacts excessively to relatively low levels of stress and takes longer than normal to return to “baseline” (normal) once the stress is removed (Linehan, 1993).

The invalidating environment of BPD family of origin

Linehan depicts an invalidating environment as one in which the personal experiences and resources of the growing child are disqualified or invalidated by the caregivers and significant others in her life (note to the reader: we use “she” to refer to the BPD client throughout this course because most of those diagnosed with BPD are female; in the Consumers’ and Carers’ Survey (McMahon & Lawn, 2011), 88 per cent of the BPD-diagnosed “consumer” respondents participating were women). The invalidating experiences could be , for example, those of not accepting the child’s personal communications as an accurate indication of her true feelings, or implying that – even if the communications were a true reflection of her feelings – having such feelings would not be valid for the circumstances.

Invalidating environments, found Linehan, tend to place a premium on self-control and self-reliance. Caregivers in such environments tend to believe that any difficulties in achieving those qualities show characterological deficits and that inability to perform to the expected standard is therefore due to the child being either lazy or unmotivated (Psych Central, 2007a).

Setting up the BPD-to-be

Let us review the chain of events put into motion by such a difficult early environment. When a sensitive, emotionally vulnerable person is told that her reactions are not an accurate indication of her feelings, or that – even if they were, they would not be appropriate for the situation – she cannot learn how to label her feelings, or trust them as valid reactions to events. Similarly, she will have greater difficulty coping with stressful situations, because her reactions (perceptions of problems) are not acknowledged. Believing that she cannot cope, she is thus led to look externally, to others, for indications of how she should feel and for help with solving problems.

By definition, an invalidating environment will be even less capable than a normal one of allowing her to make demands on others. The heightened perception of need for help combined with the diminished possibility of receiving it set up a situation of pinging back and forth between two poles: emotional inhibition, on the one hand, in order to gain acceptance and spectacular displays of emotion – in order to have feelings acknowledged – on the other. The poor-quality environment, relationally speaking, will not know how to handle such extreme oscillation, resulting in intermittent reinforcement: the response that, according to behaviourism, will most surely result in the behaviour persisting.

The consequence of persistent (partially reinforced) swinging back and forth between emotional inhibition and emotional overreaction sets up a failure to control and regulate emotions. BPD clients are characterised by a lack of skill with emotional modulation. The resultant “emotional dysregulation” combines with the person’s emotional vulnerability and the invalidating environment to produce the typical symptoms of BPD. The childhood sexual abuse experienced by most BPD clients is perhaps the most common and also most extreme form of invalidation (Psych Central, 2007a).

DBT: Roots and characteristics

Dialectical Behaviour Therapy combines standard CBT (cognitive-behavioural therapy) techniques for regulating emotion and testing reality with concepts of distress tolerance, acceptance, and mindfulness chiefly originating with Buddhist and other Eastern meditative practices (Wikipedia, 2013). Here are the main features.

1. DBT is support-oriented. Rather than merely examine what is wrong, the processes help a person to identify her strengths and build on them so that she can feel better about herself and her life.
2. DBT is cognitive-based. In true CBT fashion, DBT helps clients identify thoughts, beliefs, and assumptions that are making life harder for them. Examples of these could be: “I have to be perfect or I’m worthless”, “I got angry, so I must be a terrible person”. DBT helps clients to replace these with more helpful thoughts and beliefs, ones which make life easier to bear: for example, “I’m quite competent at tennis, but I am still a beginner at negotiation skills” or “Anger is a natural, protective emotion, and most people experience it at some time.”
3. DBT is collaborative. The goal is to have the therapist as an ally rather than an adversary as the issues are worked through. Thus, the therapist aims to accept and validate the client’s feelings at any given time, BUT – and here is one of the dialectical aspects – the therapist does not shy away from showing the client how some feelings and behaviours are maladaptive and pointing out better alternatives (Wikipedia 2013). Thus, through such a tough-love stance, the therapist achieves the synthesis of two polar opposites, e.g.: “I accept you as you are” and also, “Changing some things can bring you higher quality of life.” Clients are encouraged to work out problems in their relationships with their therapist, and therapists are encouraged to do the same with them. Moreover, therapists are encouraged to support one another in supporting the BPD clients (Psych Central, 2007b).
4. Having an experienced DBT therapist is key. Along with (3), collaboration, a high-quality therapeutic alliance between the therapist and the client is key. The emphasis in DBT is on this being a genuinely human relationship, one in which the needs of both therapist and client are considered. Due to the nature of the BPD client population, burnout is a real risk for the therapist, and thus Linehan was keen to set up a team approach, where support was not an optional extra. So clients gets DBT from the therapist and therapists give DBT to each other. There are a number of assumptions that DBT therapists are asked to make in undertaking DBT work; these are crucial for success:
   1. That the client wants to change and is doing her best at any time to achieve this.
   2. That her behaviour pattern is understandable given her background and present circumstances.
   3. Despite (2 above), however, she needs to try harder if she wants life to improve. How her life has come about is not entirely her fault, but she is responsible for making things different.
   4. Clients do not fail in DBT. If a client finds things are not improving, it is the treatment that is failing.
   5. The therapist must avoid viewing or talking about the client in pejorative terms. In particular, Linehan stressed that the word “manipulative” needed to be avoided. While BPD clients can easily evoke in people a sense of being manipulated, Linehan stressed that this was not arguably the case, as “manipulation” connotes conscious control of circumstances, whereas BPD clients are more commonly simply unskilled at managing situations and asking directly for their needs to be met.
   6. There is an acknowledgement that an unconditional relationship between therapist and client is not humanly possible; if the client tries hard enough, she can make the therapist reject her. Thus, the therapist strives to make the limits as clear as possible from the outset, and it is therefore in the client’s interest to learn to treat the therapist in a way that encourages him or her to want to continue helping. It is not in her interests to burn out the therapist. This issue is confronted openly.
   7. The therapist is asked to take up a non-defensive stance in regard to the therapy; “perfect” therapy isn’t possible, and therapists are fallible human beings, too. Mistakes will be made, and this must be accepted.
5. DBT has a longer time frame than CBT. DBT treatment usually takes at least a year, and requires considerable commitment on the part of both the client and the therapist: often twice weekly visits. This contrasts with the relatively briefer therapy mode of CBT, which is usually between 6 and 20 sessions (Adults Surviving Child Abuse, 2008; Dialectical Behaviour Therapy.com, 2009).
6. DBT uses a dialectical approach to achieve progressive change.

This article was adapted from the upcoming Mental Health Academy CPD course “Dialectical Behaviour Therapy”. For more information, visit www.mentalhealthacademy.com.au.

References

• Adults Surviving Child Abuse. (2008). Dialectical Behaviour Therapy (DBT). ASCA. Retrieved on 5 November, 2013, from: hyperlink.
• DialecticalBehaviourTherapy.com.(2009). Dialectical Behaviour Therapy in Australia. DialecticalBehaviourTherapy.com. Retrieved on 5 November, 2013, from: hyperlink.
• Grohol, J. (2009). Another treatment for Borderline Personality Disorder. Psych Central. Retrieved on 5 November, 2013, from: hyperlink.
• Linehan, M. (1993). Skills training manual for treating Borderline Personality Disorder. United States: Guilford Publications.
• Pasieczny, N. & Connor, J. (2011). The effectiveness of dialectical behaviour therapy in routine public mental health settings: An Australian controlled trial. Behaviour Research and Therapy, 2011, Jan; 49(1) 4-10. Doi: 10.1016/j.brat.2010.09.006. Epub2010 Oct 1.
• Psych Central. (2007a). Dialectical Behavior Therapy in the treatment of Borderline Personality Disorder. PsychCentral. Retrieved on 5 November, 2013, from: hyperlink.
• Psych Central. (2007b). An overview of dialectical behavior therapy. Psych Central. Retrieved on 5 November, 2013, from: hyperlink.
• Wikipedia. (2013). Dialectical behavior therapy. Wikipedia. Wikimedia Foundation, Inc. Retrieved on 5 November, 2013, from: hyperlink.