Dialectical Behavior Therapy: History and Development, Use for Borderline Personality Disorder, Controversies

16th October 2023

Dialectical Behavior Therapy (DBT) was developed by Dr. Marsha Linehan, a psychology researcher at the University of Washington, and was originally created to help people struggling with suicidal ideation. It is a useful therapy for persons who are struggling with handling their emotions. The National Association of Cognitive Behavioral Therapists includes DBT as a subset of the more general classification of Cognitive Behavioral Therapy. Other therapies under the heading of Cognitive Behavioral Therapy are, Rational Emotive Behavior Therapy, Cognitive Therapy, Rational Behavior Therapy, Rational Living Therapy, Schema Focused Therapy.

DBT combines several approaches, including standard cognitive-behavioral techniques for emotion regulation, as well as mindful awareness and distress tolerance. Some of the approaches incorporated in DBT are derived from Eastern meditative practice. DBT is used primarily in the treatment of Borderline Personality Disorder (BPD), but, as The American Institute for Cognitive Therapy explains, it has also been adapted and found useful for a wide range of psychological difficulties, including persons who struggle with emotions but who do not meet the criteria for BPD, as well as those with eating disorders.

DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of mindful awareness, distress tolerance, and acceptance largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be effective for treating BPD.

Research indicates that DBT is also effective in treating patients who represent varied symptoms and behaviors associated with spectrum mood disorders, including self-injury.

DBT treatment usually entails a weekly one and one-half to two and one-half hour skills training group, as well as weekly individual DBT therapy.

Skills training in DBT includes lessons in,

  • mindfulness
  • emotion regulation
  • distress tolerance
  • interpersonal effectiveness
  • Part of the purpose is to help you learn to be in tune fully with the moment, as an effective means of managing emotions. In this way, as crises arise, rather than interpreting them as being worse than they are, individuals learn to deal with the crisis at hand, rather than an imagined worse-case scenario. DBT endeavors to help individuals meet objectives in relationships positively and pro-actively.

    Linehan created DBT in response to her observation of therapist burnout from difficulties with patient motivation and cooperation with standard therapies. She started to develop her concepts when recognizing that those patients who struggled with suicidal ideation often had been raised in oppressive and invalidating environments. Unconditional acceptance was of necessity.

    Her version of unconditional acceptance derived from Thich Nhat Hanh's metaphysically neutral version rather than Carl Rogers' humanistically "positive" version. Thich Nhat Hanh was a Vietnamese Zen Master, poet, peace and human rights activist. "Mindfulness," in particular, is associated with the Zen philosophy of Thich Nhat Hanh. Along with that was the necessity of enlisting the support of her patients, that is, their willingness to commit to change and participate in therapy.

    Elements of Eastern religion and Zen Buddhism are incorporated into Dialectical Behavioral Therapy. Photo: Buddhist monk. Tevaprapas Makklay

    Linehan united commitment to the core conditions of acceptance and change through the Hegelian principle of dialectical progress, in which thesis and antithesis - synthesis, and proceeded to assemble a modular array of skills for emotional self-regulation. Hegel was a 19th century philosopher who focused upon history and logic, a history in which it sees, in various perspectives, that "the rational is the real" and a logic in which it sees that "the truth is the Whole."

    Therefore, the philosophy behind DBT derived from both modern Western psychology, such as Cognitive Behavioral Therapy and what is commonly referred to as "assertiveness training," as well as Eastern philosophical influences, such as Zen Buddhist mindfulness meditation. Add to this a dash of tough love, and this amalgamation of practicality, modern psychological practice, and Eastern meditation and philosophy, produced a form of treatment, that is effective for many.

    Purpose of the individual component of DBT therapy
    An individual component in which the therapist and patient discuss issues that come up during the week, recorded on diary cards and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority, followed by therapy interfering behaviors. Then there are quality of life issues and finally working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, skills group is discussed and obstacles to acting skillfully are addressed.

    The individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions

    Group therapy with DBT
    Specific skills learned in group therapy are divided into four units: core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.

    Skill Training Components of DBT

    Mindfulness is one of the core concepts behind all elements of DBT. Mindfulness is the capacity to pay attention, nonjudgmentally, to the present moment. Mindfulness is all about living in the moment, experiencing one's emotions and senses fully, yet with perspective. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist and Zen Buddhist practice, though the version taught in DBT does not necessarily involve specific religious or direct metaphysical concepts.

    Interpersonal effectiveness
    Interpersonal response patterns are based on concepts in assertiveness training and also involved developing problem-solving skills. Skills can be and are learned for appropriately dealing with interpersonal conflicts. Effective interpersonal skills need to be learned, developed and practiced.

    Emotion regulation
    Individuals with borderline personality disorder, and persons who are suicidal, may be emotionally intense. They might become angry, frustrated, depressed or anxious in situations that might seem "normal" for average persons. Dialectical behavior therapy teaches skills for regulating emotions. Some of these include:

  • Identifying and labeling emotions
  • Identifying obstacles to changing emotions
  • Reducing vulnerability to emotion mind
  • Increasing positive emotional events
  • Increasing mindfulness to current emotions
  • Taking opposite action
  • Applying distress tolerance techniques
  • Distress tolerance
    The goal of DBT is to become capable of calmly recognizing negative situations and dealing with them, rather than becoming overwhelmed, overreacting or hiding from them. This allows individuals to make wise decisions and act rationally, rather than simply reacting.

    Four sets of crisis survival strategies are incorporated in DBT: distracting, self-soothing, improving the moment, and thinking of pros and cons. Acceptance skills include radical acceptance, turning the mind toward acceptance, and willingness, which signifies working within one's present situation, as opposed to willfulness, which is interpreted as meaning, trying to impose one's will regardless of reality.

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    Possible Controversies with Dialectic Behavior Therapy - Please Note:
    This site does not recommend or endorse all facets of DBT. However, some of the principles of DBT, can be effective. (In public schools, for example, there is a separation of religion and education. Some might consider the DBT practice of mindfulness as a form of religion, inasmuch as Eastern religious and Zen Buddhist philosophies form a part of the treatment and philosophical underpinnings of certain facets of DBT. Teaching religion on an academic level, however, is accepted in public schools). Some conservative Christians, Muslims or Jews might object to facets of DBT derived from Eastern religious philosophies.

    It has been noted that DBT has been effective for many, more effective than standard treatments, probably in large part, because of the specific training of therapists, and the intensity, specific and regularity of the treatment schedule. Also of note is the DBT treatment for Borderline Personality Disorder, does generally not include use of prescription drugs, which have not been found to increase effectiveness of the treatment.