Dialectical Behavioral Therapy (DBT)

What is the approach?

Dialectical behavior therapy (DBT) is a form of cognitive behavioral therapy, specifically developed for borderline personality disorder (BPD), in which the clinician attempts to motivate the client towards change in behavior while simultaneously validating existing thoughts and feelings. (DeVylder) The goal of dialectical behavior therapy is to minimize maladaptive behaviors related to impulse control and emotion regulation, especially those that may result in self-injury or death. (DeVylder) The desired outcome of DBT is a resolution of maladaptive behaviors related to impulse control and emotion regulation, especially those behaviors that may result in self-injury or death. (DeVylder)

According to the Lineman Institute,

dialectical behavior therapy includes four sets of behavioral skills, mindfulness, distress tolerance, interpersonal effectiveness and emotion regulation. Mindfulness is the practice of being fully aware and present in this one moment. With distress tolerance, patients learn how to tolerate pain in difficult situations. With interpersonal effectiveness, patients learn how to ask for what they want and to say no while maintaining self-respect and relationships with others. With emotion regulation, patients learn how to change the emotions that they want to change.

How does DBT prioritize treatment targets?
Clients who receive DBT typically have multiple problems that require treatment. Dialectical behavior therapy uses a hierarchy of treatment targets to help the therapist determine the order in which problems should be addressed. The treatment targets in order of priority are:
1 Life-threatening behaviors: First and foremost, behaviors that could lead to the client's death are targeted, including all forms of suicidal and non-suicidal self-injury, suicidal ideation, suicide communications, and other behaviors engaged in for the purpose of causing bodily harm.
2 Therapy-interfering behaviors: This includes any behavior that interferes with the client receiving effective treatment. These behaviors can be on the part of the client and/or the therapist, such as coming late to sessions, cancelling appointments, and being non-collaborative in working towards treatment goals.
3 Quality of life behaviors: This category includes any other type of behavior that interferes with clients having a reasonable quality of life, such as mental disorders, relationship problems, and financial or housing crises.
4 Skills acquisition: This refers to the need for clients to learn new skillful behaviors to replace ineffective behaviors and help them achieve their goals.

Dialectical behavior therapy is divided into four stages of treatment (Linehan Institute). The stages are defined by the severity of the client's behaviors, and therapists work with their clients to reach the goals of each stage.
In Stage 1, the client is miserable and their behavior is out of control: they may be trying to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviors.

When clients first start DBT treatment, they often describe their experience of their mental illness as "being in hell." The goal of Stage 1 is for the client to move from being out of control to achieving behavioral control.
In Stage 2, they're living a life of quiet desperation: their behavior is under control but they continue to suffer, often due to past trauma and invalidation. Their emotional experience is inhibited. The goal of Stage 2 is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated.
In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and find peace and happiness. The goal is that the client leads a life of ordinary happiness and unhappiness.
In stage 4, which is not needed for all clients, clients find a deeper meaning through a spiritual existence. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and

freedom.

Dialectical behavior therapy brings together four treatment modalities (Christina Olenchek, 2008). The first is Individual psychotherapy. These sessions, which are generally held once a week, are designed to help the client find ways to reduce or eliminate borderline behaviors. The second is Group skills training. These sessions, which also usually meet weekly, concentrate on four skills sets: core mindfulness skills, interpersonal effectiveness, emotional regulation, and distress tolerance skills. The third is Telephone consultation. Making therapists available by phone gives clients a healthy way to reach out for assistance during times of crisis and helps them learn how to generalize skills they have learned in therapy. And the fourth is Case consultation meetings for therapists. Because working with clients with borderline personality disorder can be so taxing for therapists, Linehan believes that therapists must work as a team and hold meetings to offer each other guidance and support.
(Christina Olenchek, 2008)

Effectiveness of DBT
One study (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) compared a group of women with borderline personality disorder who received DBT for one year with a group of women with borderline personality disorder who received treatment as usual. Members of the DBT group were less likely to commit parasuicidal acts (self-harm with little or no intention to cause death), more likely to stay in therapy, and required fewer days of inpatient psychiatric hospitalization. (Olenchek, 2008)
A study by Safer, Telch, and Agras (2001) found that women with bulimia nervosa reported significantly lowered levels of binging and purging after being treated with DBT compared with women in wait-list status.
Linehan, Schmidt, Dimeff, Craft, Kanter, and Comtois (1999) compared DBT with treatment as usual for a group of drug-dependent suicidal women displaying borderline personality disorder. The DBT group had a much lower dropout rate (36%) than the treatment as usual group (73%). The DBT group also showed a significant decline in substance abuse.
DBT also has been shown to be an effective treatment for female veterans with borderline personality disorder, depressed older adults, and other populations (Koons, Robins, Tweed, Lynch, Gonzalez, Morse, Bishop, Butterfield, & Bastian, 2001; Lynch, Morse, Mendelson, & Robins, 2003).
(Olenchek, 2008)

How effective would the approach be with people of various cultural and socioeconomic backgrounds? Why?

Because dialectical behavior therapy is a form of cognitive behavior therapy, the process is generally short term and more goal oriented.

Due to the structure of the therapy, dialectical behavior therapy is more likely to be covered by insurances, which allows more people access to the therapy. Dialectical behavior therapy is generally used more among women, because of how they are diagnosed. Women are more likely than men to be diagnosed with borderline personality disorder, thus resulting in more women using dialectical behavior therapy to treat their symptoms.
Dialectical behavior therapy would be a good approach for someone who is African American because according to Aponte, 1994; Exum and Moore, 1993; Paniagua, 1994, a therapist should use a time-limited, problem-solving approach and directive techniques.
In the Asian community, a directive, structured, goal-oriented, problem-solving approach that focuses on alleviating specific symptoms is usually preferred. Asian clients expect therapists to give concrete advice and view the therapist as a knowledgeable expert and authority figure. (Paniagua,

1994)
Dialectical behavior therapy is also good for Hispanics. When working with a Hispanic client, a therapist is usually best advised to be active and directive and to adopt a multimodal approach that focuses on the client’s behavior, affect, cognitions, interpersonal relationships, and biological functioning.