EmpathicPivot

DBT is based on CBT but with modifications to include a dialectical approach to problem solving that discourages absolute truths and allows for both acceptance and change, validation of a person’s experiences and mindfulness that serves as a core skill supporting other skills that are to be learned (Bohnenstiehl, 2017).

A key tenet of DBT is biosocial theory that proposes that some people do not have the innate ability to manage their emotions which becomes an issue in situations in which they feel invalidated, rejected or dismissed (Gregory, 2020).

Behavioural theory in DBT focuses on recognising the triggers of maladaptive behaviours that are due to previously learned associations and connections (Haddock, 2016). It also focuses on the consequences of the maladaptive behaviours that act to develop and maintain these behaviours over time (Haddock, 2016). 

Lineham (1993), who developed DBT, adopted the term dialectics—based on the principles of interrelated wholeness, polarity and continuous change—to describe certain techniques that had inadvertently developed when she was offering CBT to people with borderline personality disorder. It was found on reflection that she would encourage people to accept their current feelings and situation (validation) rather than change, and offer a seemingly paradoxical no-win choice of either accepting reality or commit to change, she also deliberately exaggerated consequences to make a point, and she would switch between an empathetic person-centred style to confrontational and challenging (Lineham, 1993). This led to the development of strategies that balance acceptance of a person’s emotions, behaviour and thoughts with encouraging change which is the “central dialectical tension in DBT” (Lineham, 1993, p. 126).

Person-in-environment is particularly relevant to biosocial theory in DBT in the importance of acknowledging current invalidating environments in the person’s life and the related interventions using validation and acceptance (Gregory, 2020).

In DBT people undertake a highly structured skills development process to learn new behaviours which are reinforced over time (Bohnenstiehl, 2017). There are four stages in the process which Bohnenstiehl (2017) outlines as:

Stage 1 – gaining control of behaviours to build a “Life Worth Living” (p. 305) – consists of a weekly skills training group and weekly individual counselling and may take 12 to 18 months;

Stage 2 – experiencing emotions fully and connecting to the person’s environment;

Stage 3 – building an ordinary life, solving problems and increasing self-respect;

Stage 4 – decreasing the sense of incompleteness and moving to fulfilment. (pp. 302-304)

During the weekly skills training group sessions people learn modules developed by Lineham. They are: Core Mindfulness; Interpersonal Effectiveness; Walking the Middle Path; Emotion Regulation and Distress Tolerance (Bohnenstiehl, 2017). As outlined by Lineham (1993) the process begins with the practitioner and person agreeing on goals and the person understanding and committing to the therapy including ground rules. The practitioner must then work on developing a positive therapeutic relationship with the person, as the practitioner may be the only means of reinforcing change in behaviour (Lineham, 1993).  

The practitioner role appears complex and highly structured, even if seen as flexible by Lineham (1993). They are required to follow a range of procedures, assessments, techniques and strategies as laid out by Lineham (Bohnenstiehl, 2017). These include:

• Weekly completion of behaviour chains using any of eight defined commitment strategies to address impediments to change;
• Case formulation to identify target behaviours;
• Suicide assessment and lethality assessment linked to a detailed behaviour chain;
• Change procedures used to constantly teach and reinforce new skills – contingency, exposure-based, cognitive modification and skills training;
• Dialectical strategies – eight core strategies that emphasis the main dialectical aims of DBT;
• Validation strategies – six levels of validation to ensure the person feels validated; and
• Stylistic strategies – reciprocity when the practitioner is warm and genuine and irreverence such as asking “how’s that working out for you” (p. 309) when a person is advocating for maladaptive behaviour. (pp. 305-308)

To accept themselves and their situation while working towards change, to learn, apply and practice skills to modify their behaviour, and participate in individual and group meetings (Haddock, 2016).

Borderline personality disorder, addiction, eating disorders, domestic and family violence, self-harm, PTSD, depression, anxiety and mood disorders (Haddock, 2016).

Reduction in self-harming behaviours and behaviours that interfere with the person’s quality of life and an increase in skills to manage negative emotions, improved interpersonal relationships and tolerate distress (Haddock, 2016).

Is applicable to groups of people who may be difficult to treat (Haddock, 2016).

DBT is highly structured, intensive, requiring a high-level of client commitment, has prescribed interventions and requires special training which means it is more complex to manage and limits client suitability as well as the number of practitioners available (Haddock, 2016).

Bohnenstiehl, A. (2017). Dialectical behavior therapy. In R. Cottone (Ed.), Theories of counseling and psychotherapy: Individual and relational approaches (pp. 298-317). Springer Publishing. 

Gregory, V. (2020). Psychological perspective: Psychodynamic, humanistic, and cognitive-behavioural theories. In R. Ow & W. Poon (Eds.), Mental health and social work (pp. 39-51). Springer Nature. https://doi.org/10.1007/978-981-13-6975-9_5

Haddock, L. (2016). Dialectical behavior therapy. In D. Capuzzi & M. Stauffer (Eds.), Counseling and psychotherapy: Theories and interventions (pp. 312-342). American Counseling Association. 

Lineham, M. (1993). Cognitive behavioural treatment of  borderline personality disorder. The Guilford Press.