Dialectical Behaviour Therapy

 

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What is DBT?

The behavioural skills training is based on a model of treatment called Dialectical Behaviour Therapy (DBT). DBT is a broad-based cognitive-behavioural treatment and was originally developed for chronically suicidal individuals diagnosed with borderline personality disorder.

Since then, multiple clinical trials have been conducted demonstrating the effectiveness of DBT not only for BPD, but also for a wide range of other disorders and problems, including both under control and over control of emotions and associated cognitive and behavioural patterns. Furthermore, an increasing number of studies suggest that skill training alone is a promising intervention for a variety of populations. DBT, including DBT skills training, is based on a dialectical and biosocial theory of psychological disorder that emphasizes the role of difficulties in regulating emotions, both under and over
control, and behaviour. Emotion deregulation has been linked to a variety of mental health problems stemming from patterns of instability in emotion regulation, impulse control, interpersonal relationships, and self-image. DBT skills are aimed directly at these dysfunctional patterns. The overall goal of DBT skills training is to help individual’s change behavioural, emotional, thinking, and interpersonal patterns associated with problems in living.

Dialectical philosophy rests on assumptions that guide its application. First, dialectics recognize inherent contradictions and tensions that arise within us, between us, in situations, and in the world. Rather than allowing these oppositions to negate each other, the philosophy seeks synthesis, balance, and flow, transforming the crystallization of opposites into fluid movement. This movement represents the second assumption that change is continual and will lead to new contradictions and crises. What is effective in this moment both affects and has no bearing on what is effective in the next. Thus, dialectics require constant attention to and (re) orientation toward context as each moment evolves into the next. The goal of dialectics is responsive synthesis to meet demands and be effective.

 

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Often, responsive dialectics involve seeing new and different perspectives and engaging in middle-ground behaviours.

The most fundamental dialectic in DBT is validation versus change (Linehan, 1993a).

Validation is acceptance-based, meeting clients where they are without the expectation that they or their reality be different. Validation and acceptance are powerful and healing, but they are only one side of the equation. At some point, movement toward change is needed, counterbalancing acceptance of what currently “is.” DBT recognizes that acceptance of the person, in the moment, is what opens the door to change. Rogers purportedly said, “The curious paradox is that, when I accept myself just as I am, then I can change.” DBT embraces such a statement, but, in contrast to client-centred therapy, it pushes toward change when the conditions of acceptance are sufficient to allow it. The tension between
acceptance and change highlights the dialectical philosophy of holding two opposites at the same time, embracing the wisdom of both and seeking the synthesis of the two. When a client feels validated, movement toward change can be made, and, as the client struggles to change, movement back to validation and acceptance are indicated.

Acceptance is difficult for many reasons. For some, the word itself conjures up the idea that an unwanted reality is approved of or is something to be resigned to, being static and unworkable. For painful emotions, physical sensations, and events, the natural inclination is to reject the reality, as if fighting what is will somehow lead to escape and avoidance of the pain. This reaction is human and should be treated non-pathologically. Acceptance requires validation that communicates the inherent sense in emotions and behaviours that are otherwise misunderstood, rejected, and pathologized. Acceptance of the “unacceptable” requires a shift that comprehends reality given the circumstances that construct it.