Dialectical Behavioral Therapy (DBT) is an evidence-based treatment to help provide stabilization to people struggling with chronic suicidal ideation and usually, childhood experiences of trauma. These experiences, among other symptoms, were later categorized into the diagnosis we now know as Borderline Personality Disorder (BPD). Dr. Marsha Linehan’s research not only established hope for a previously rendered “untreatable” population, but also helped to name a diagnosis that has given meaning to millions of trauma survivors. Now, we can debate whether a diagnosis of BPD offers one meaning or only applies stigma. In my experience, orienting a person to DBT and within this context, collaboratively exploring BPD criteria and its origins (a complex interplay of emotional sensitivity and childhood trauma) has offered my clients a great deal of relief, clarity, and inspiration. Dr. Linehan’s publications offer an extremely compassionate lens to include the following excerpt,
“Although I am no fan of the term ‘borderline,’ I do not believe that we will reduce prejudice against these difficult-to-treat individuals by changing labels. Instead, I believe that the solution has to be the development of a theory that is based on sound scientific principles, highlighting the basis of the disordered ‘borderline’ behaviors as normal responses to dysfunctional biological, psychological, and environmental events. It is by making these individuals different in principle from ourselves that we demean them. And perhaps, at times, we demean them to make them different.” She goes on to state,
“One of the main goals of my theoretical endeavors has been to develop a theory of BPD that is both scientifically sound and nonjudgmental and non-pejorative in tone. The idea here is that such a theory should lead to effective treatment techniques as well as to a compassionate attitude. Such an attitude is needed, especially with this population: our tools to help them are limited; their misery is intense and vocal; and the success or failure of our attempts to help can have extreme outcomes.”
DBT has evolved over the decades and is now successfully utilized for substance use disorders, eating disorders, and general anger management. It is generally recommended for people struggling with managing or regulating difficult emotions, often resulting in harmful behaviors. A backlash of any therapeutic modality gaining traction in the mental health field becomes the eventual lack of fidelity. In other words, the essence of the teaching becomes lost in translation. I want to acknowledge this is often seen within eastern and indigenous meditative practices. The evolution of using meditation within psychotherapy has been gradual since the 1990s. In more recent years, I’ve seen an influx of information pertaining to “mindfulness” meditation in pop psychology specifically, which has its benefits and drawbacks. Dr. Linehan uses many concepts found in Zen Buddhism as part of DBT’s curriculum. However, she weaves education into the introduction of mindfulness, as both a concept and practice, that pays homage to its original teachers in a way that is not as commonplace today. You can learn more about the origins of mindfulness meditation and how it has been incorporated into western mental health treatment by reading my blog post here.
The biggest misconception I see from both clinicians and clients alike is that DBT is simply a practice of coping skills. DBT has been deduced from a psycho-dynamic, behavioral trauma treatment to a set of handouts. While coping skills are a significant portion of the program, this information is meant to extend beyond “coping” and incorporates research derived from attachment theory, nervous system regulation, and mindfulness. Skills cannot be effectively taught or modeled without the safe container of the therapeutic relationship, which is why I believe stand-alone DBT Skills Training groups (one example of “modified DBT”) are only helpful to some. The essence of the trauma healing begins when the clinician can illustrate the tension between acceptance and change, which is called a dialectic. Furthermore, this dialectic is constantly felt and attended to when the individual therapist implements both validation and gentle confrontation as part of the therapeutic alliance. Individual therapy and the relationship between clinician and client is encouraged to be extremely authentic, which at times will include a variety of communication strategies meant to facilitate raw emotional experience. Similar to psycho-dynamic therapy, DBT normalizes transference. The clinician’s ability to understand and withstand the transference allows ample opportunities to notice (i.e. mindful awareness without judgement) trauma re-enactments and help the client practice new ways of tolerating relational closeness.
Critics of DBT often name it as a manualized treatment. Though there is certainty a manual of sorts, the philosophical underpinnings and nuance of clinical skill involved is what creates powerful change for clients. Positive research outcomes have categorized DBT as an “evidence-based” treatment. However, results can only be achieved when the treating clinician truly understands the spirit and essence of the model. This is only gained through clinical experience, significant time spent in formal trainings, and ongoing consultation. Expertise is not granted by focusing only upon the specific coping skills DBT includes as part of its curriculum, which is often what we find in simplified DBT trainings.
At best, DBT is a life-changing transformative treatment for trauma survivors. At worse, clients are left feeling their set of painful internal experiences to be oversimplified. They receive the message that if they only “try harder” to learn and practice coping skills, problems will simply vanish. A more common scenario: clients walk away from a modified DBT approach with excellent tools to manage intense emotions and behaviors but continue to struggle with trauma re-enactments and persisting feelings of emptiness that result from an unstable sense of Self. Modified DBT is rarely set up to be a long-term program, whereas the comprehensive model strictly holds that a minimum of six months is required for participation and a year as most effective. My prior experience with DBT program development and implementation included a month orientation and commitment phase with generally one year of full program participation, which includes weekly DBT psychotherapy and weekly DBT Skills Training group. After graduation, most clients continue weekly psychotherapy and benefit from weaving in other therapeutic modalities to the firm foundation we create as phase one of their healing journey.
A comprehensive DBT program, as set out by Dr. Linehan’s research, contains these elements:
- Weekly individual DBT psychotherapy
- Weekly DBT Skills Training group
- Coaching phone calls outside session for assistance in generalizing skills to difficult situations
- Weekly DBT consultation group for all rendering providers to review philosophical principles, learn and practice DBT skills (+ other clinical interventions), and discuss complex client cases
If you are a clinician or facility interested in organizing an individualized training for your team, contact me directly. If you are a client looking for an assessment to determine if a comprehensive DBT program is appropriate for you, please reach out. Assessments always include brief diagnostic formulation, treatment recommendations, and referrals. As a provider, I currently work with a modified DBT approach with people for which this is appropriate, though I ascribe as closely to the model as I am able to in private practice. I often help my clients seek additional services that act as assists to our work. Finally, as a commitment to my clients, I will assess ongoing if we may ever need to facilitate a transfer of care to an organization that does house a comprehensive DBT program.
In summary, DBT is a thoughtful treatment model that provides skills to be taught, modeled, and facilitated to increase dialectical tension. Trauma-induced behaviors are replaced with ones that reflect a solidified and clear sense of Self. Childhood wounds are collaboratively witnessed by both the client and clinician in a solution-focused way that offers containment of the experience. Clients have the unique opportunity to receive honest feedback from a safe other that helps to modify over-anxious or dependent attachment styles resulting from lack of attunement in childhood. For many clients, DBT will be their stand-alone trauma treatment. For others, DBT offers a strong and long-lasting foundation that allows for the evolution of personal growth and healing. Stay tuned for a future blog post, Beyond DBT.