Dialectical behavior therapy (DBT) is a comprehensive, evidence-based treatment for borderline personality disorder (BPD). The patient populations for which DBT has the most empirical support include parasuicidal women with a borderline personality disorder (BPD), but there have been promising findings for patients with BPD and substance use disorders (SUDs), persons who meet criteria for a binge-eating disorder, and depressed elderly patients.
What is the goal?
The goal of dialectical behavior therapy is to help you learn to manage your difficult emotions by letting yourself experience, recognize and accept them. As you learn to accept and regulate your emotions, you also become more able to change your harmful behavior and for this, therapists use a balance of acceptance and change techniques.
Five functions of treatment:
DBT is a comprehensive program of treatment consisting of individual therapy, group therapy, and a therapist consultation team. It’s a program of treatment, rather than some treatment conducted by a practitioner in isolation.
Within DBT, the assumption is that patients with BPD either lack or need to improve several important life skills, including those that involve
- Regulating emotions (emotion regulation skills)
- Paying attention to the experience of the present moment and regulating attention (mindfulness skills)
- Effectively navigating interpersonal situations (interpersonal effectiveness), and
- Tolerating distress and surviving crises without making situations worse (distress tolerance skills).
If the skills learned in therapy sessions do not transfer to patients’ daily lives, then it would be difficult to say that therapy was successful. As a result, a second critical function of DBT involves generalizing treatment gains to the patient’s natural environment. This function is accomplished in skills training by providing homework assignments to practice skills and troubleshooting regarding how to improve upon skills practice.
Improving motivation and reducing dysfunctional behaviors:
The third function of DBT involves improving patients’ motivation to change and reducing behaviors inconsistent with a life worth living. This function primarily is accomplished in individual therapy. Each week, the therapist has the patient complete a self-monitoring form (called a “diary card”) on which he or she tracks various treatment targets (e.g., self-harm, suicide attempts, emotional misery). The therapist uses this diary card to prioritize session time, giving behaviors that threaten the patient’s life (e.g., suicidal or self-injurious behaviors) highest priority, followed by behaviors that interfere with therapy (e.g., absence, lateness, non-collaborative behavior), and behaviors that interfere with the patient’s quality of life (e.g., severe problems in living, unemployment, or severe problems related to Axis I disorders).
Enhancing and maintaining therapist capabilities and motivation:
Another important function of DBT involves maintaining the motivation and skills of the therapists who treat patients with BPD. Although helping multi-problematic BPD patients can be stimulating and rewarding, these patients also engage in a potent mix of behaviors that can tax the coping resources, competencies, and resolve of their treatment providers (i.e., suicide attempts, repeated suicidal crises, behaviors that interfere with therapy). As a result, one essential ingredient of an effective treatment for BPD patients is a system of providing support, validation, continued training and skill-building, feedback, and encouragement to therapists.
Structuring the environment:
A fourth important function of dialectical behavior therapy involves structuring the environment in a manner that reinforces effective behavior/progress and does not reinforce maladaptive or problematic behavior. Often, this involves structuring the treatment in a manner that most effectively promotes progress. Typically, in DBT, the individual therapist is the primary therapist and is “in charge” of the treatment team. He or she makes sure that all of the elements of effective treatment are in place, and that all of these functions are met.