Dialectical Behavioural Therapy

Dialectics is a branch of Greek philosophy, where opposing points of view are discussed to try and establish the real truth of a situation. By working through the two opinions, hypothesis and antithesis, a synthesis (conclusion) is reached.

Dialectics sounds amazing as a way of debating issues, but how does a practice of such beautiful reasoning apply to the often messy process of therapy? Marsha Linehan, a psychology researcher at Washington University in the 1980s, saw a strong connection. She developed Dialectical Behavioural Therapy (DBT) as a way to treat individuals who were chronically suicidal, or who suffered from Borderline Personality Disorder (BPD).

The results from DBT have been pretty impressive from the start, and not only with suicidal and BPD clients. Substance addictions, depression, bipolar and other mood disorders, and Post-Traumatic Stress Disorder (PTSD) have all responded to the treatment. Using DBT to deal with eating disorders such as bulimia, anorexia, binge eating disorders and orthorexia has also been successful.

Those who deal with eating disorders often say that in some cases the disordered eating is the primary issue, and in others it’s the symptom of BPD, depression or something else. Detangling the cluster can be incredibly difficult, but whichever side of the coin sufferers find themselves on, it’s comforting to know that DBT is one of the things that can help.

The Core Ideas of DBT

Like a lot of different psychological treatments, DBT developed as a modified form of Cognitive Behavioural Therapy (CBT). The CBT approach is focused on identifying core belief systems and faulty modes of thinking and then taking action to deal with them, and is more structured than traditional psychotherapy. Each of these approaches clearly have a place, and lucky are the clients whose treatment encompasses both.

But back to DBT. Essentially, it combines the CBT therapeutic techniques of reality-testing and emotional regulation with the concepts of mindfulness, distress tolerance and acceptance – which are largely derived from meditative practices in Buddhism. Dialectics assumes that everything is interconnected; that change is an inevitable constant and that integrating opposites creates a closer approximation to whatever the truth of a situation actually is.

By combining different philosophical and psychological approaches, DBT is able to help clients find  balance between the seemingly opposite concepts of change and self-acceptance. The term “radical acceptance” is often used in DBT, and refers to the acknowledgement of situations and facts without judgement.

In so doing, individuals are better able to see what is really going on and to take responsibility for making positive behavioural changes. Therapists work with their clients to resolve the change/self-acceptance contradiction, and act as allies rather than adversaries. Getting results with DBT takes serious commitment from both parties; it’s an active engagement. And the work you put in really is reflected in what you get out.

Therapy Components of DBT

The different aspects and tools of DBT help individuals get concrete, discernible results, based on all the lofty notions mentioned above. Successful treatment should empower people to understand their reactions and develop coping skills that allow them to more easily navigate daily life and interactions with others.

There are 4 components to DBT, and they’re all equally important. One-on-one sessions with a therapist allow clients to reflect on what behaviours are coming up and how to modify them as necessary; group meetings provide instruction on the DBT modules (explained below) in a classroom-like setting; brief telephone coaching helps individuals to tap into the new skills they are learning in specific situations as they arise; and consultant team meetings support the health professionals who are involved in the case.

The consultant team groups really reflect how much of a partnership DBT is, between those who are giving and receiving the therapy. One of Linehan’s key original findings was that therapists struggled with burnout after working with resistant clients. Not only does DBT put both parties on an equal footing, it also requires that professionals employ the techniques in their own lives, to look after their own wellbeing. Discussing these issues and supporting each other in the consultant team meetings is a vital piece of the puzzle.

DBT Modules

The modules that DBT teaches in group sessions, and that are then discussed and applied in individual and phone consultations as well as daily life, are mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

Mindfulness taps into the idea of focusing on the present moment, rather than the future or the past, without judgement – that all-important “radical acceptance”. Distress tolerance is also about acceptance – rather than trying to escape pain or unpleasant emotions, clients are encouraged to acknowledge them.

Techniques for dealing with these feelings, without suppressing them, include relaxation exercises, listening to music, and even prayer. Distress tolerance tools tie into emotional regulation; people who suffer from serious mood swings learn to identify their feelings and what they can do to regulate them, and then take action to do just that – including consciously increasing radical acceptance and deploying distress tolerance techniques like little torpedoes that improve state of mind.

Finally, “interpersonal effectiveness” refers to coping with conflict, asking for what you need, and being aware of what someone else needs. Clients learn how to interact meaningfully with others, while developing and maintaining their own self-respect. For example, a BPD sufferer might be able to identify what someone else needs but will then use that knowledge to get what they themselves want. Through interpersonal effectiveness tools, they could work on just offering support and care.

No Treatment is an Island

What is being realised more and more, by people in therapy and by those giving it, is that different approaches can be used on one client to great effect. Schema therapy, DBT and the CBT that they both sprung from might all be part of one psychologist’s arsenal, and used at different times on the same individual.

The radical acceptance and working on interpersonal skills seen in DBT dovetail beautifully with the principles of 12-Step fellowships, as does the idea of asking for help from a higher power to manage distress. As someone commented when learning about DBT, “This is what I’ve been doing in therapy; I just didn’t know the name”. Bringing the different strands together needs to be done well, by a trained professional but it can be very successful.