Cognitive · 1991
Dialectical Behaviour Therapy (DBT)
Change arises from balancing acceptance and transformation while the person learns skills for building a life worth living.
Dialectical Behaviour Therapy (DBT) is an integrative cognitive behavioural treatment developed by Marsha M. Linehan and initially evaluated with women with borderline personality disorder and chronic suicidal or self-harming behaviour. Its biosocial formulation holds that emotion dysregulation emerges from the transaction between high emotional vulnerability and environments that invalidate, oversimplify or punish private experience, so that problem behaviours are understood as learned attempts to regulate intolerable affect, obtain help, escape aversive situations or solve problems without yet having effective alternatives. The intervention organises treatment through an explicit hierarchy of targets, combines validation with problem-solving, uses behavioural analysis, contingency management, exposure and cognitive modification, and teaches skills of mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. Standard DBT is a multimodal programme integrating individual psychotherapy, group skills training, telephone coaching and a consultation team for therapists; the therapeutic relationship is used as a context of acceptance, motivation, learning and generalisation, maintaining a dialectical tension between caring for the person as they are and requiring the changes necessary for them to stay alive and build a valued life.
Theory of change
A person changes when they replace behaviours that regulate pain in the short term with effective skills, within a relationship that integrates validation, responsibility and contextual practice.
Core ideas
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Emotion dysregulation is the organising problem
DBT formulates much borderline behaviour as a consequence of high emotional vulnerability and of deficits in modulating arousal, inhibiting mood-dependent actions and returning to baseline. Impulsive, interpersonal and identity-related behaviours are analysed by the function they serve within that regulatory system, which displaces moralising explanations and directs intervention towards skills, contingencies and contexts. (Linehan, 1993a, chapters 2 and 3).
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Person and environment construct one another
The biosocial theory describes a continuous transaction: emotional sensitivity provokes environmental responses, those responses may invalidate or reinforce extreme expressions, and the person then adopts patterns of self-invalidation that increase future vulnerability. The case is understood as a recursive, contextual system, so that change may require modifying both personal repertoires and the consequences and relationships of the environment. (Linehan, 1993a, chapter 2).
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Accepting and changing are simultaneous tasks
DBT holds that a therapy focused solely on change may repeat the invalidation, while acceptance without a demand for change may confirm that life will remain unbearable. The intervention maintains both positions: the present response makes sense within its context and, at the same time, the person needs to learn and do something different in order to reach their goals. (Linehan, 1993a, chapters 4, 7 and 8).
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The hierarchy protects treatment from the tyranny of crisis
Crises generate intense pressure to address the most urgent content of the moment, even when that content is not the most important target. DBT's hierarchy maintains life and the viability of therapy first, then quality of life and skills, and only when sufficient stability exists does it allow the treatment to focus on trauma, self-respect and goals. (Linehan, 1993a, chapters 5 and 6).
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Every target behaviour requires a functional explanation
Chain analysis replaces global categories with a reconstruction of vulnerabilities, prompting events, links and consequences. The aim is to discover what the behaviour solved, what reinforced it and where an alternative response can be inserted, so that intervention rests on data from the episode rather than on attributions about character or intent. (Linehan, 1993a, chapter 9).
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Motivation is treated as a variable behaviour
Wanting to change and being able to sustain the necessary actions are neither stable states nor prerequisites the person must supply. DBT makes motivation, effort and commitment targets of treatment, uses specific strategies to strengthen them and holds that the therapist and the programme must change when the intervention fails to produce sufficient adherence. (Linehan, 1993a, chapters 4 and 9).
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Skills must be learned in the contexts where they fail
A person may understand and perform a skill when calm and lose it under high arousal, conflict or shame. DBT therefore combines structured teaching, rehearsal, homework, telephone coaching and subsequent analysis, aiming for mindfulness, regulation, tolerance and interpersonal effectiveness to appear in the real environment and at the moment of need. (Linehan, 1993a, chapters 4, 6 and 11; Linehan, 1993b, chapters 2 to 6).
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Mindfulness creates the space in which to choose
Observing, describing and participating non-judgementally, one-mindfully and effectively makes it possible to detect emotions, thoughts and urges before they become automatic action. Wise mind symbolises the integration of emotion, reason and intuition and provides a common attentional foundation for all the other modules. (Linehan, 1993b, chapter 7).
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Tolerating pain prevents it from multiplying
DBT distinguishes unavoidable pain from the suffering added by rejecting reality and from the harm produced by impulsive responses. Crisis and acceptance skills do not necessarily resolve the original problem, but they prevent it from worsening and preserve the conditions needed to apply effective changes afterwards. (Linehan, 1993b, chapter 10).
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The therapeutic relationship is a real contingency
The therapist's care, attention, honesty, limits and reactions have behavioural and relational functions, so they cannot be considered a neutral background. DBT uses the relationship to reinforce skilful approximations, practise conflict and repair, model reciprocity and motivate change, while protecting the therapist through limits and consultation. (Linehan, 1993a, chapters 10, 12, 13 and 15).
Influences
- Behaviour therapy
- Cognitive behavioural therapy
- Radical behaviourism
- Suicide prevention and crisis intervention
- Dialectical philosophy
- Zen Buddhism and mindfulness
- Person-centred therapy
- Paradoxical and strategic systemic therapies
- Relapse prevention
- Social learning theory
Key references
- Linehan, M. M. (1993a). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press. ISBN 978-0-89862-183-9.
- Linehan, M. M. (1993b). Skills Training Manual for Treating Borderline Personality Disorder. New York: The Guilford Press. ISBN 978-0-89862-034-4.
- Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48(12), 1060-1064.
- Linehan, M. M., Heard, H. L., & Armstrong, H. E. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50(12), 971-974.
- Linehan, M. M., & Koerner, K. (1992). Behavioral theory of borderline personality disorder. En J. Paris (Ed.), Handbook of Borderline Personality Disorder. Washington, DC: American Psychiatric Press.
- Basseches, M. (1984). Dialectical Thinking and Adult Development. Norwood, NJ: Ablex.
- Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: The Guilford Press.
- Hanh, T. N. (1976). The Miracle of Mindfulness: A Manual on Meditation. Boston: Beacon Press.
- May, G. G. (1982). Will and Spirit. San Francisco: Harper & Row.