BPD Awareness Month 2022 – Dialectical Behaviour Therapy
Dr Navroop Johnson, Consultant General Adult Psychiatrist and member of the CPsychI Personality Disorder Special Interest Group, gives a clinical overview of the models and theories of Dialectical Behaviour Therapy (DBT), one of the most effective and common treatments for Personality Disorders.
This article is part of our information series marking Borderline Personality Disorder Awareness Month this May. You can read more in the series below this post and watch out for a further patient perspective coming soon.
Dialectical Behaviour Therapy (DBT) is a treatment devised by US psychologist Marsha Linehan for those with diagnosis of emotionally unstable personality disorder (EUPD), also known as borderline personality disorder (BPD). DBT came into being following extensive research into the available literature on psychosocial treatments for other disorders, such as anxiety disorders and depression, while attempting to assemble a package of evidence-based, cognitive-behavioural interventions that directly targeted suicidal and self-harm behaviour. Most notably, DBT is designed to convey acceptance of the patient and to help the patient accept themselves, their emotions, thoughts, and the world around them.
Principles governing DBT
The biosocial theory
DBT is based on a theory of EUPD that attempts to explain the pathogenesis of the latter and encourages clinicians to focus on emotional regulation in treatment. According to the biosocial theory, people with EUPD are born with a biological disposition toward emotion vulnerability 1, which consists of a low threshold for responding to emotional stimuli and intense emotional responses. The patient’s environment also invalidates these emotional responses by ignoring, dismissing, or punishing them, or by oversimplifying the ease of coping/problem solving.
As a result, the person does not develop skills needed to regulate emotions, and may resort to instantly gratifying or even self-destructive ways to cope with emotions (e.g. deliberate self-harm)2. Based on the biosocial theory, DBT takes the approach of focusing on emotions, and encompasses the primary goal of improving patients’ quality of life by reducing negative behaviours and increasing positive coping strategies3 4.
Dialectical philosophy in DBT
Dialectical philosophy underpins the main ethos of DBT and makes it different to other Cognitive Based Therapies (CBT). The term ‘dialectical’ comes from the idea that bringing together two opposites in therapy – acceptance and change – brings better results than either one alone 5. A unique aspect of DBT is its focus on acceptance of a patient’s experience as a way for therapists to reassure them and balance the work needed to change negative behaviours.
Acceptance and mindfulness in DBT
In DBT, mindfulness skills help patients focus on what is happening in the here and now, rather than existing in the past or imagining the future, often viewed through a negative lens. Mindfulness skills are generally designed to teach patients to non-judgementally observe their current experience, paying full attention to the facts of this experience, and trying to not be diverted by other thoughts in their mind 6. Another acceptance intervention in DBT is called radical acceptance, which essentially involves accepting the experience of the present moment for what it is, without struggling to change it or wilfully resisting it. This skill teaches the patients to wholeheartedly accept any given situation, especially if resolution is not in their control, as resisting it may lead to further distress. Validation is another acceptance intervention in DBT which involves acceptance of the patient and their experiences by the therapist1.
Elements and structure of DBT
DBT is a comprehensive programme of treatment consisting of skills group training, individual therapy, and a therapist consultation team. In this way, DBT is a programme rather than a single treatment method conducted by a practitioner in isolation, although there are variations in clinical practice with different models of skills-only training or DBT-based individual therapy depending on resources available to clinicians. In all cases, however, it is critical that any adaptation of DBT attempts to fulfil the following five elements:
1. Improving positive skills
DBT as a therapy assumes that patients either lack or need to improve several important life skills, including those that involve:
- Regulating negative emotions (emotion regulation skills)
- Paying attention to the experience of the present moment (mindfulness skills)
- Improving efficacy of interpersonal relations (interpersonal effectiveness)
- Tolerating distress without making situations worse (distress tolerance skills)7
These four areas form the modules of a DBT programme which are delivered in weekly sessions lasting two to two -and-a-half hours each.
2. Generalising skills
The skills learned in weekly group sessions need to be transferred to patients’ daily lives. This is accomplished in three ways. Firstly, therapists encourage patients to engage in homework assignments to practice skills. Secondly, individual therapists help patients to understand areas of their lives whereby these skills would be useful. Thirdly, the therapist is available by phone between sessions to help the patient apply skills when they are most needed (e.g. in a crisis), although patients are strongly advised that these telephone sessions are not for therapy but mainly for coaching.
3. Reducing negative behaviours
A third function of DBT involves improving patients’ motivation to change and reducing behaviours inconsistent with a life worth living. This function primarily is accomplished in individual therapy. Each week, the therapist asks the patient to complete a diary card on which they track various treatment targets. The therapist uses this to prioritise session time, giving behaviours that threaten the patient’s life (e.g. suicidal or self-harm) highest priority, followed by behaviours that interfere with therapy (e.g. absence, lateness, wilfulness), and behaviours that interfere with the patient’s quality of life (e.g. accommodation, child support, marital disharmony, unemployment, or co-morbid mental health issues).
This hierarchy is based on the principle that if lower importance issues are dealt first, the patient may not even be there for the next session due to their more serious self-harm behaviours. After prioritising the behavioural targets, the therapist uses the method of chain analysis to help the patient figure out the chronology of events leading up to the negative behaviour and the points at which they could have intervened to result in a different outcome. The therapist also encourages the patient to apply skills learned in skills training to problem solve their issues1.
4. Supporting the therapist
Another important function of DBT involves maintaining the motivation and skills of the therapists. Although helping complex patients is stimulating and rewarding, these patients can also tax the coping mechanisms, skill-set, and commitment of their treatment providers due to their repeated negative behaviours. As a result, one essential ingredient of an effective treatment for EUPD patients is a system of providing support and validation for all the therapists involved. Another important aspect of this support is continued training and skill building by means of shared and supervised learning. To address this, a standard DBT programme includes a therapist consultation meeting, for which DBT therapists meet once a week for approximately one to two hours. The therapists help each other problem-solve ways to implement effective treatment in the face of specific clinical challenges. In addition, therapists endeavour to maintain a positive attitude toward their patients along with monitoring and reducing therapist burnout.
5. Structuring the environment
A further functional mode of DBT involves structuring the environment in a manner that reinforces effective behaviour/progress and does not reinforce maladaptive or problematic behaviour. Often, this involves structuring the treatment in a manner that most effectively promotes progress. The main reason behind this is because, even if a therapist can successfully change patients’ behaviours in therapy, the patient will struggle to maintain these positive changes unless their immediate environment is not supportive. This can be achieved by involving the patients’ families in psycho-education around their difficulties and the efforts being made in DBT to resolve same. The individual therapist may undertake to do this for their patient or if the resources allow, the group of therapists may invite families for group psycho-education. This type of psycho-education may also need to be extended to other staff in the service, e.g. emergency department staff1.
1. Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL (1991) Cognitive behavioural treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 48: 1060-1064.
2. Linehan MM, Tutek DA, Heard HL, Armstrong HE (1994) Interpersonal outcome of cognitive behavioural treatment for chronically suicidal borderline patients. Am J Psychiatry 151: 1771-1776.
3. Lynch TR, Chapman AL, Rosenthal MZ, Kuo JR, Linehan MM (2006) Mechanisms of change in dialectical behaviour therapy: theoretical and empirical observations. J Clin Psychol 62: 459-480.
4. Kroger C, Schweiger U, Sipos V, Arnold R, Kahl KG, et al. (2006) Effectiveness of dialectical behaviour therapy for borderline personality disorder in an inpatient setting. Behav Res Ther 44: 1211-1217.
5. Van den Bosch LMC, Koeter MW, Stijnen T, Verheul R, Van den Brink W (2005) Sustained efficacy of dialectical behavior therapy for borderline personality disorder. Behav Res Ther 43: 1231-1241.
6. Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, et al. (2006) Two year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviours and borderline personality disorder. Arch Gen Psychiatry 63: 757-766.
7. Linehan MM, Dimeff LA, Reynolds SK, Comtois KA, Welch SS, et al. (2002) Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug Alcohol Depend 67: 13-26.
Borderline Personality Disorder Awareness Month 2022 – Blog Series:
What is Borderline Personality Disorder – by Dr Paul Matthews
Addressing 6 Myths Around Borderline Personality Disorder – Dr Molly Bredin
Treatments for Borderline Personality Disorder – by Dr Paul Matthews
Development of Treatment for Personality Disorder in Adult Mental Health Services – Position Paper by the CPsychI Personality Disorders Special Interest Group
Treatment for BPD – HSE Ireland
Information on Dialectical Behaviour Therapy – HSE Ireland
Symptoms, Causes, Treatment and Diagnosis – HSE Ireland, General Information on Personality Disorder
PersonalityDisorder.org.uk – Developed by the UK Department of Health.
About Borderline Personality Disorder – Mind, Uk-based mental health charity
Personality disorders: symptoms, treatments, self-care – resource by MindWise, mental health charity in Northern Ireland
Borderline Personality Disorder can be treated and achieve ‘good response – Article by Priscilla Lynch
The Wrong Kind of Mad podcast – Hollie Berrigan and Keir Harding talk about issues associated with “personality disorder”.