Dialectical behavior therapy (DBT): Components, stages, and modules
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Written bytherapist.com team
Last updated: 09/14/2023
Dialectical behavior therapy (DBT) is a type of therapy originally developed to treat chronically suicidal individuals with borderline personality disorder (BPD). It is particularly helpful in teaching people impulse control and emotion regulation. DBT integrates the principles of cognitive behavioral therapy (CBT) with the mindfulness skills derived from Zen and Buddhist practices.
The term “dialectical” refers to the fact that two seemingly opposite forces can coexist at the same time. Although DBT comprises many dialectics, the most prominent dialectic is that of acceptance and change, which forms the foundation of dialectical behavior therapy.
DBT teaches clients how to balance and synthesize these two opposing forces so they can find emotional healing. Although seemingly paradoxical, DBT maintains that acceptance is necessary for change. You must learn to accept yourself as you are while also acknowledging the need to change.
Acceptance does not mean that you like or agree with your current reality. It simply means that you understand what is. When you come to this understanding, you are better able to embrace what needs to change. That’s because you cannot work to change something if you don’t accept that it exists in the first place.
Acceptance is also a key component of the client-therapist relationship in DBT. Clients need to feel a certain level of acceptance and non-judgment from their therapist in order to pursue committed change. Because of this foundation of acceptance, DBT is particularly effective for clients who may be initially skeptical or resistant to therapy.
Dialectical behavior therapy is built on the foundation of biosocial theory. Biosocial theory posits that mental health disorders are the result of two conditions:
- Biological vulnerability: People are born with biochemical vulnerabilities, particularly in the brain, that predispose them toward certain types of mental health disorders. Whether it’s an imbalance of certain chemicals or an abnormality in the physical structure of the brain, biological vulnerabilities do not always manifest as mental health disorders, but they do increase a person’s risk.
- Social history: The environment in which you are raised imparts certain narratives about your identity, worth, strengths, weaknesses, and role in life. The sum of your past experiences is defined as your social history. Your social history may exacerbate or mitigate your biological vulnerabilities. Trauma can cause physical changes to the body’s hormone production that may create new vulnerabilities.
Essentially, biosocial theory is an answer to the famous nature vs. nurture debate. Are you born with tendencies toward certain mental health struggles, or is your mental health shaped by your family, environment, and childhood experiences? Biosocial theory says the answer is both.
DBT was originally developed to treat borderline personality disorder. More recent adaptations have demonstrated that it’s also helpful for other high-risk disorders characterized by self-destructive behavior, such as:
DBT helps people embrace “both-and” thinking instead of “either-or.” The dialectical approach allows two apparent opposites to be true: You can accept your life non-judgmentally, and you can also work toward committed, effective change.
DBT incorporates four basic treatment components, helps clients through four specific stages, and comprises four modules to help clients better manage their emotions, thoughts, and behaviors.
The structure of dialectical behavior therapy consists of four major components:
- Individual therapy: DBT individual therapy looks like most standard individual sessions of therapy. You’ll meet with your therapist once a week for approximately an hour.
- Group skills training: DBT also includes a group therapy component focused on skills training. These classes meet weekly for approximately two to three hours.
- Phone coaching: DBT therapists offer coaching to clients over the phone in times of crisis.
- Therapist consultations: DBT therapists also require support and therapy in order to facilitate therapy in a healthy way. DBT requires therapists to create a consultation group that meets weekly to support one another and consult on cases.
Dialectical behavior therapy focuses on four stages of treatment:
- Crisis intervention: The first step of DBT is to prevent imminent self-destructive behavior that threatens or harms the safety of the individual or the safety of others. This means addressing suicidal ideation, self-harm, and other harmful or dangerous behaviors.
- Resistance reduction: The next step of DBT is to address any resistance to actively participating in treatment. Clients may need to safely explore past trauma and unearth emotional pain in order to proceed with treatment. Therapists may need to address a client’s tardiness or non-compliance. Committing to abstain from dangerous or life-threatening behaviors is a crucial step in proceeding with treatment.
- Skills development and application: Once clients commit to treatment, they can begin to develop new skills to improve their quality of life. Skills may include goal setting, developing higher self-esteem, learning healthy coping strategies, and more.
- Spiritual connection: Many clients benefit from seeing their life in the context of a greater meaning or purpose. Stronger spiritual connection can help clients maintain their motivation to continue pursuing a healthier, fuller life.
Dialectical behavior therapy is made up of four basic modules:
- Mindfulness: Clients learn how to focus on the present moment and cultivate an awareness of their thoughts and feelings without judgment.
- Distress tolerance: Clients learn how to get through difficult or distressing situations and soothe themselves instead of trying to escape via self-destructive behaviors.
- Emotion-regulation: Clients learn skills to better understand and manage their emotions so they can avoid engaging in impulsive, self-destructive behaviors.
- Interpersonal effectiveness: Clients learn how to communicate their needs, relate to others, and create and respect boundaries.
Although dialectical behavior therapy is based on cognitive behavioral therapy, they are two distinct modes of treatment. In contrast to traditional CBT, dialectical behavior therapy has a greater focus on accepting difficult or painful feelings rather than fighting against them. DBT is particularly effective for clients who may struggle with extreme or self-destructive behaviors. It’s also typically more effective than CBT for clients who are resistant to change or skeptical of therapy in the first place.
Acceptance and commitment therapy (ACT) shares the foundation of acceptance and change on which DBT is also built. However, ACT is a much less structured treatment option. Instead of requiring group therapy and therapist consultations, ACT can exist simply as a form of individual therapy.
Additionally, DBT emphasizes a more collaborative approach, allowing clients to work with individual therapists, group leaders, and other clients they’re in class with, while therapists also work together. ACT occurs in the context of only one collaborative relationship between client and therapist.
DBT has proven effective for people struggling with borderline personality disorder and suicidal ideation. Although more research is needed regarding its efficacy for other types of mental health disorders, there is evidence regarding its utility in treating eating disorders, mood disorders, posttraumatic stress disorder, and other issues.
DBT requires large investments in both time and resources. Typical DBT treatment plans require clients to undergo three to four hours a week of individual and group therapy, not including the time needed to complete homework assignments. Such a large time investment may be prohibitive for certain clients.
Self-destructive behaviors like self-harm and suicidal ideation may be the result of two very different personality styles: lack of control (characterized by overwhelming moods and impulsive behavior) and overcontrol (characterized by rigid adherence to certain rules and intolerance for mistakes).
For people who struggle with lack of control, DBT is often most effective. However, for people who struggle with overcontrol, a different kind of treatment may be required. Radically open dialectical behavior therapy (RO-DBT) is a form of DBT meant to help people whose self-destructive behaviors are the result of overcontrol, not a lack of control. Click here to find a RO-DBT therapist near you.
If you are struggling with borderline personality disorder or other self-destructive behaviors, dialectical behavior therapy may be right for you. Click here to find a DBT therapist near you.
If you are currently experiencing a crisis, help is available now:
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