“What on earth is DBT?” “DBT – I would never want to do that!” “DBT is only for clients with very severe diagnoses”, “DBT is behavioral – ugh!”
As DBT takes on a bigger and bigger presence in the psychotherapy community, many psychotherapists and clients make these statements. This short and informal article is a very, very brief description of a simple, complex, easy, difficult, fun, hard, highly effective approach to learning how to live a better life. (The previous sentence used some examples of dialectics.) Dialectical Behavioral Therapy is a validation, mindfulness, and skills- based psychotherapy method. The DBT philosophy, approach and interventions can be helpful to any client and to any psychotherapist.
A History: In the late 1970s, Marsha Linehan, a behavioral psychologist based at the University of Washington, was simultaneously studying and practicing Zen Buddhism and working with adult women with chronic suicide attempts, suicidal ideation, and urges to self-harm. She began to wonder whether the awareness practices in Buddhism would be helpful to her clients, since she believed that a client has to be aware of the problem in order to understand and change it. She was also noticing that her patients who were receiving standard Cognitive Behavioral Therapy found the constant focus on change in CBT to be invalidating. Her clients needed validation for their “problem behaviors” – these were behaviors developed in an attempt to be effective, not problematic.
She began to experiment with teaching her patients the non-judgmental stance, attention to the present moment, and focus on effectiveness found in mindfulness practice. Mindfulness creates, among other qualities, a uniquely validating atmosphere and environment in psychotherapy.
DBT for BPD
Linehan was also noticing that most of her patients met the criteria for Borderline Personality Disorder. Linehan evolved and refined a bio-social theory of BPD that postulates that people who have significant difficulty regulating emotions often have a history of growing up in an invalidating environment. (Linehan sees an “invalidating environment” as spanning the spectrum between abusive on one end and, on the other end, a mis-match between a sensitive child and a well-meaning parent who doesn’t know how to cope with that child.) Linehan theorizes that many of the extreme behaviors associated with BPD are attempts to validate and regulate emotions. Linehan began to see that her patients didn’t have effective life skills in many areas.
DBT Can Be Useful to Everyone
Dialectical Behavioral Therapy was designed for the severe and chronic multi-diagnostic, difficult-to-treat patient with both Axis I and Axis II disorders. However, DBT is NOT just for people with BPD. DBT focuses on identifying a problem and identifying effective solutions and behaviors. For example, substance abuse, eating disorders, inappropriate anger, over-sleeping, suicide and parasuicide are ineffective solutions to problems. People with depressive disorders, Bipolar Disorder, anxiety disorders, BPD, OCD, PTSD and ORDINARY LIFE PROBLEMS often use ineffective solutions to their problems.
At Mindfulness Therapy Associates, my colleagues and I use many of the techniques, and certainly the stance of DBT, with all of our clients, who range from clients with ordinary life problems to clients with more extreme mental disorders. In our DBT Skills Training Group, Lori Schwanbeck and I often emphasize that, although we do not have BPD, we have grown and changed by using DBT skills and that we believe that anyone can benefit from these skills.
What On Earth Is Dialectics?
A “dialectic” stance emphasizes the synthesis of opposites. For instance, one synthesis of opposites inherent in DBT is the combination of eastern mindfulness practices and western behavioral therapy. Multiple tensions simultaneously occur in therapy with clients with difficult-to- treat disorders. Life is chaotic and contradictory. These conditions are often intolerable to those clients and often lead to ineffective attempts to tolerate the contradictions – self-harm and suicide, for instance. Dialectical thinking is a skill that can replace the rigid, argumentative and polarized position often taken by such a client – DBT teaches that life is full of opposites and that there are ways we can balance in the middle.
The DBT therapist holds a dialectical stance: non-judgmental and transparent and focused on insisting on change. The DBT therapist validates the reasons why her client is using certain (outmoded) coping strategies and behaviors – these behaviors actually make sense, in a way — while pushing the client to develop and use more skillful, effective, coping behaviors. Many of the skills taught in DBT Skills Training have to do with recognizing and living with the fact that life is full of dialectics: two seemingly opposite truths existing in the same moment.
DBT is Warm and Relational
Despite what many people (and maybe especially psychotherapists in the Bay Area) think, DBT and good behavioral therapy is not cold and distant. It is collaborative, transparent, irreverent, practical and effective.
Above all, DBT is validating. During my training with Marsha Linehan, she said that she suspects that DBT works because it’s “validating therapy.” The DBT therapist works within the relationship with her client, using the positive regard developed between therapist and client to reinforce the development of skills.
DBT is Not Just Skills Training
DBT is primarily an individual psychotherapy method that focuses on 1) increasing motivation, 2) reinforcing new skills (taught in a separate, skills training group) and 3) managing problem behaviors. Stage One DBT focuses on decreasing life- threatening behaviors, therapy-interfering behaviors and quality-of-life interfering behaviors. For the client with extreme and difficult-to-treat issues, Stage One DBT can be lengthy. For such a client, when skills are learned and integrated into life, Stage Two focuses on quiet desperation and increasing emotional experiencing. Stage Three focuses on problems in living, ordinary happiness and ordinary unhappiness.
For the less disordered client, the stages of treatment overlap and interweave but the early stage of therapy do focus on increasing behavioral skills to increase the quality of life.
But It’s Also Skills Training
Many people who’ve heard a little about DBT think of the DBT Skills Training Group. Although skills training is only one piece of DBT psychotherapy, it is fundamental. When Marsh Linehan began to develop DBT, she noticed the deficit of life skills among her clients. Clients who have been significantly invalidated are clients who were never taught how to effectively and skillfully get their needs met. The skills most needed among her patients were: Mindfulness (awareness), Interpersonal Effectiveness (how to effectively tell people what you want and need), Emotion Regulation (how to understand and manage emotions) and Distress Tolerance (how to manage emotions in a situation you cannot change).
DBT Skills Training teaches people how to increase these skills and how to decrease identity confusion, emptiness, cognitive dysregulation, interpersonal chaos, fears of abandonment, labile affect, excessive anger, impulsive behaviors, suicide threats and parasuicide (self-harm). DBT Skills Training groups are psychoeducational: skills are taught, practice homework is assigned, successes applauded, failures are deconstructed, application problems are validated and solved, and, at every session, mindfulness is practiced.
Don’t Be Afraid of DBT – It’s Fabulous!
Anyone who’s taken a DBT training with any of the senior DBT trainers will know what I mean by this. For everyone else, let me say, it is! DBT is big, and effective, and, often, fun and funny. DBT therapists are real, they’re disappointed by failures, optimistic about figuring out how to avoid future failures, and enthusiastic about success – thus, the fabulousness. DBT is not reductive or exclusive — many other psychotherapies can be integrated into DBT, and vice versa. Above all, DBT makes life better, really, it does!
One of the great pleasures of being a DBT therapist is seeing how DBT Psychotherapy and DBT Skills Training can make a difference in the quality of a person’s life in a relatively short period of time. DBT skills are easy to understand and easy to practice. Each client is better at some skills and has difficulties with others, as is human. Many clients, by changing their behaviors and practices, can begin a process of essential transformation that goes beyond behavior and problem solving. The combination of internal mindfulness practice and external living skills practice is powerful. For many people, DBT is an opening to greater access to spiritual and human connection.∞
For more information about DBT, please feel free to contact me at