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What Is Dialectical Behavior Therapy?

Dialectical behavior therapy (DBT) uses mindfulness techniques to reduce a person’s intrusive thoughts and behaviors. The therapy approach has been used to treat borderline personality disorder, depression, eating disorders and addiction.

Dialectical behavior therapy primarily is used for people battling suicidal thoughts and self-injurious behaviors. This form of treatment involves four components: individual psychotherapy, group skills training, phone coaching and ongoing support from a team of therapists.

DBT is a modified form of cognitive behavioral therapy, a psychotherapy used to help people deal with a range of mental health problems, including depression, suicidal thoughts and substance use disorders. However, DBT differs from CBT in that DBT encourages clients to learn to accept stressing thoughts, feelings and behaviors rather than reject them. Therapists aim to help clients find a balance between acceptance and change to overcome their problems.

Over the years, DBT has been altered to address substance use disorders. Multiple studies show that this updated approach, called DBT-SUD, can reduce drug use in people with borderline personality disorder, a mental disorder characterized by unstable relationships, distorted self-image and impulsiveness. Although research involving the impact of DBT on drug use is limited, additional research could indicate DBT’s effectiveness in treating other substance-using populations.

The History of DBT

In the 1970s, Dr. Marsha Linehan developed DBT after she attempted to use CBT to treat adult women who had battled suicidal ideation, suicide attempts and self-harm.

Linehan and a team of researchers investigated the effectiveness of standard CBT on women with suicidal thoughts caused by psychological pain, a symptom of borderline personality disorder. She found the therapy technique wasn’t always effective, partially because of its focus on rejecting painful thoughts.

“So then [Linehan] had this brilliant epiphany,” Dr. Alec Miller, professor in the Department of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine, told the Child Mind Institute. “[She blended] the acceptance strategies of mindfulness with the change technologies of CBT to create this dialectical behavior therapy.”

Linehan altered standard CBT by integrating strategies of acceptance. This allowed therapists to explain that the problematic thoughts many people harbored were okay. Through this modification to CBT, clients could learn to trust themselves.

Researchers combined elements of acceptance and change to create dialectical strategies, which helped therapy sessions run more smoothly.

DBT and Substance Abuse

After developing DBT, Linehan led a study to determine whether the approach was effective in treating women battling borderline personality disorder and drug dependence.

Researchers compared participants who engaged in DBT with a control group who received standard treatment. Those who were receiving treatment during the pretreatment evaluation were permitted to stay with their psychotherapists during the study. Others entered alternative substance abuse or mental health programs.

The results showed that DBT was more effective than standard treatment in treating people with borderline personality disorder and a substance use disorder involving opioids, cocaine, amphetamines, sedatives, hypnotics and anti-anxiety medications. Researchers found that DBT clients showed reduced substance abuse, and they were more likely to continue therapy than those in traditional treatment.

A 2015 study published in the journal Addictive Behaviors used DBT in conjunction with cultural, spiritual and traditional practices to treat 229 adolescents at an inpatient rehab facility. The results showed 96 percent of adolescents improved or recovered from their substance use disorders over time.

Another 2015 study, published in Current Opinion in Psychology, reviewed multiple reports about the use of DBT-SUD in individuals with borderline personality disorder and multiple drug dependences.

DBT-SUD is a modified version of dialectical behavior therapy that incorporates substance abuse prevention strategies to help individuals overcome addiction. Through this approach, therapists use problem-solving techniques to discuss the importance of harm reduction and a realistic approach to relapse avoidance.

Researchers concluded that DBT-SUD has shown promise in treating drug disorders among women with borderline personality disorder, and it may be helpful in treating other drug-using populations.

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What Are the Stages of DBT?

Before engaging in dialectical behavior therapy, a health care professional generally explains the process of this treatment approach. The therapist and client collaborate to develop realistic goals to be achieved during each of the four stages of therapy.

Stage One

During stage one of DBT, individuals strive to gain control over their reckless behaviors, which could include heavy drinking or drug abuse. Those entering this level of therapy often have a history of self-harming, suicidal thoughts or mental illness.

Stage one is designed to help people overcome these behaviors and achieve stability. It also aims to decrease behaviors that interfere with therapy. Through this stage, clients learn to increase their ability to manage stress and effectively interact with others.

Stage Two

Those in stage two of DBT have learned to manage their behaviors, but their emotional health remains an issue. They often suffer in silence. Upon entering this level of therapy, people may experience drug or alcohol abuse, have symptoms of an eating disorder or engage in nonsuicidal self-injury.

During the second stage, clients develop goals to be achieved during therapy. These targets are contingent on the severity of existing problems and the relationships between them. Individuals also learn self-validation techniques and how to maintain focus and control emotional stress.

Stage two aims to relieve traumatic stress. A therapist may help someone with post-traumatic stress disorder and alcohol dependence through interventions that involve behavioral analyses, exposure therapy and techniques to improve self-validation and mindfulness.

Stage Three

People in stage three of DBT often have problems with achieving happiness. In response, therapists help clients increase self-respect and self-esteem, identify life goals and recognize a normal balance of happiness and unhappiness.

Stage Four

Many people have trouble achieving a sense of connectedness, joy and freedom. Stage four of DBT uses long-term psychotherapy to help individuals overcome these feelings and live a life of spiritual fulfillment.

What Skills Are Taught in DBT?

Dialectical behavior therapy incorporates four skills intended to help people overcome their distressing thoughts and unhealthy behaviors. Each set of skills has its own unique characteristics that help clients better understand their emotions.

Mindfulness

Mindfulness is a mental state characterized by being aware and accepting of the present moment, including our thoughts, feelings and environment. Mindful people focus on the moment without judgement.

This skill teaches clients to control their thoughts and to avoid letting their minds dictate their lives. They can use this knowledge to maintain a positive state of mind, to better understand their emotions and to effectively accept stress rather than push it away.

Distress Tolerance

Individuals who regulate their thoughts and feelings during tough times often make wise choices. Others react to highly stressful situations in a hostile manner, which may lead to regrettable decisions. Distress tolerance teaches people to make sound decisions in difficult moments.

Through this module, therapists teach crisis survival skills to clients. This information helps distressed individuals avoid exhibiting antagonistic behaviors that could exacerbate problems. They learn to tolerate stress rather than change it.

Interpersonal Effectiveness

Interpersonal effectiveness teaches clients to deal with others in healthy, effective ways. People develop an understanding of how to ask for something and say no when necessary. In doing so, individuals learn how to handle difficult situations and improve communication and relationships.

Emotion Regulation

Emotion regulation helps people understand and control their emotions. This set of skills teaches clients to better understand and express their emotions in order to alleviate psychological pain. The approach allows clients to avoid feeling overwhelmed by their thoughts.

The Effectiveness of DBT for Co-Occurring Disorders

Studies indicate that dialectical behavior therapy, like CBT, has neurobiological effects on the brain.

A 2014 study published in the Journal of Psychiatric Research tested the effect DBT had on individuals with borderline personality disorder, an illness that has been linked to depression, and drug and alcohol abuse. In the study, researchers took MRI scans of patients as they viewed unpleasant, neutral and pleasant photographs. Scans were conducted before and after DBT treatment.

The study found that DBT reduces activity in the amygdala, a part of the brain that is often disturbed in people with borderline personality disorder. By reducing amygdala activity, DBT improves emotional behavioral health.

DBT and Suicidal Behaviors

DBT was developed to treat people with symptoms that include self-harm. Over the years, several studies have tested this therapy approach on people with such behaviors.

In a 2016 study funded by the American Foundation for Suicide Prevention, Dr. Anthony Ruocco and colleagues investigated DBT’s effect on brain activity by evaluating 29 borderline personality disorder patients with self-harming behaviors. Participants underwent brain image scanning while completing a computer task before and after DBT therapy.

Ruocco saw a change in brain activity after DBT treatment, and the therapy reduced self-harm behavior. After treatment, patients showed increased activity in the prefrontal cortex, a part of the brain that controls emotional and behavioral health.

DBT helps individuals respond to difficult emotions in a more adaptive way. This form of treatment has also proven to reduce suicidal episodes and psychiatric hospitalizations, according to a report by Yale University.

DBT and PTSD

Borderline personality disorder and PTSD share symptoms such as emotional avoidance, impulsive behavior and the development of relationship problems. This suggests that DBT could be used to treat PTSD.

A 2013 study published in the journal Psychotherapy and Psychosomatics tested the effectiveness of DBT-PTSD in treating people with borderline personality disorder and PTSD caused by childhood sexual abuse. DBT-PTSD blends elements of DBT and trauma-specific interventions.

The results showed that this treatment approach greatly improved the PTSD symptoms in many participants.

DBT has been used to treat people with PTSD prior to more specific treatment approaches such as exposure therapy. DBT uses elements of mindfulness to help these individuals develop emotional regulation and distress tolerance.

DBT and Symptoms of Depression

A 2007 study published in the Journal of the American Academy of Child & Adolescent Psychiatry tested DBT methods on adolescents with bipolar disorder. Nine of 10 patients completed treatment. At the conclusion of therapy, patients saw a decrease in self-injurious behavior, suicidality and symptoms of depression.

“Dialectical behavior therapy may offer promise as an approach to the psychosocial treatment of adolescent bipolar disorder,” the study authors concluded.

A study published in the journal Behavior Therapy studied the efficacy of DBT in women veterans with borderline personality disorder. Researchers found DBT to be effective in reducing thoughts of hopelessness, depression and angry outbursts.

The findings suggested that DBT can be effective in treating other groups of patients, including those without suicidal or self-injurious behavior. In a randomized clinical trial cited by the study authors, researchers found that DBT is more effective than treatment as usual for drug-dependent women with borderline personality disorder.

DBT and Eating Disorders

This treatment method works for people suffering from eating disorders as well. A 2001 study found that DBT significantly decreased symptoms of bulimia among women. These symptoms include binge and purge behaviors.

A 2006 study on DBT found this method of treatment helpful for people suffering from substance use disorders, binge eating disorders or depression. Researchers also found that this treatment method helped reduce suicide attempts, emergency room visits and parasuicidal behavior such as self-harm.

A 2013 study published in Behaviour Research and Therapy tested the efficacy of DBT on people with binge eating disorder. More than 88 percent of these individuals were women, and the average age of participants was about 43 years old.

After treatment, individuals who received DBT reported having fewer binge-eating episodes in the past month than study participants on a wait list for treatment with DBT. DBT clients also reported having an improved quality of life six months after therapy.

Does DBT Work for Children and Teens?

Dialectical behavior therapy has been used to help people overcome a variety of issues ranging from substance abuse to mood and personality disorders. But does this therapy work for children and adolescents? A 2011 study answered affirmatively.

The report, published in the journal Child and Adolescent Mental Health, used DBT on children aged 8 to 11 who experienced symptoms of depression, anxiety and suicidal thoughts. After treatment, children reported having better healthy coping skills. They also showed decreases in depressive symptoms, suicidal ideation and other unhealthy behaviors.

“These promising preliminary results suggest that continued development of DBT for children with more severe clinical impairment is warranted,” the authors concluded.

Health care professionals often use individual therapy, group skills training, weekly consultation team meetings and family therapy when treating teens with DBT. This allows parents and adolescents to learn together and share feedback. Teens also are encouraged to call their therapists when in crisis.

Dr. Jill Emanuele, a clinical psychologist at the Child Mind Institute, said DBT for teens focuses on eating properly, getting enough sleep, taking medications and avoiding substance use. Adolescents also learn to recognize and manage suicidal urges.

Finding DBT Treatment

Many independent therapists, organizations and institutions in the United States use dialectical behavior therapy to treat teens and adults with borderline personality disorder. The Linehan Institute offers workshops, books and webinars designed to teach people more about DBT.

Additionally, rehab centers throughout the country have incorporated dialectical behavior therapy into their evidence-based treatment strategy. It is particularly helpful for those who have trouble managing emotions and intrusive thoughts.

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