Dialectical Behavior Therapy in a Nutshell

Linda Dimeff Marsha M. Linehan

The Behavioral Technology Transfer Group Department of Psychology
Seattle, Washington University of Washington
Seattle, Washington

INTRODUCTION essential to support client and therapist capabilities, and

Dialectical behavior therapy (DBT) is a comprehensive 5) enhances therapist capabilities and motivation to treat
cognitive-behavioral treatment for complex, difficult-to- clients effectively. In standard DBT, these functions are
treat mental disorders (Linehan, 1993a,b). Originally divided among modes of service delivery, including
developed for chronically suicidal individuals, DBT has individual psychotherapy, group skills training, phone
evolved into a treatment for multi-disordered individuals consultation, and therapist consultation team.
with borderline personality disorder (BPD). DBT has
since been adapted for other seemingly intractable
ORIGINS OF DBT
behavioral disorders involving emotion dysregulation,
DBT grew out of a series of failed attempts to apply the
including substance dependence in individuals with BPD
standard cognitive and behavior therapy protocols of the
(Linehan, Schmidt, Dimeff, Craft, Kanter, & Comtois,
late 1970s to chronically suicidal clients. These
1999; Dimeff, Rizvi, Brown, & Linehan, 2000), binge
difficulties included:
eating (Telch, Agras, & Linehan, in press), depressed,
suicidal adolescents(Miller, 1999; Rathus & Miller,
2000), depressed elderly (Lynch, 2000), and to a variety 1. focusing on change procedures was frequently experienced
of settings, including inpatient and partial as invalidating by the client and often precipitated
hospitalization, forensic settings (Swenson, Sanderson, withdrawal from therapy, attacks on the therapist, or
Dulit, & Linehan, in press; McCann & Ball, 1996; vacillations between these two poles;
McCann, Ball, & Ivanoff, under review).
2. teaching and strengthening new skills was extraordinarily
DBT is based on a combined capability deficit and
difficult to do within the context of an individual therapy
motivational model of BPD which states that (1) people
session while concurrently targeting and treating the
with BPD lack important interpersonal, self-regulation clients motivation to die and suicidal behaviors that had
(including emotional regulation) and distress tolerance
occurred during the previous week;
skills, and (2) personal and environmental factors often
both block and/or inhibit the use of behavioral skills that
3. individuals with BPD often unwittingly reinforced the
clients do have, and reinforce dysfunctional behaviors.
therapist for iatrogenic treatment (e.g., a client stops
DBT combines the basic strategies of behavior therapy
attacking the therapist when the therapist changes the topic
with eastern mindfulness practices, residing within an
from one the client is afraid to discuss to a pleasant or
overarching dialectical worldview that emphasizes the
neutral topic) and punished them for effective treatment
synthesis of opposites. The term dialectical is also meant
strategies (e.g., a client attempts suicide when the therapis t
to convey both the multiple tensions that co-occur in
refuses to recommend hospitalization stays that reinforce
therapy with suicidal clients with BPD as well as the
suicide threats).
emphasis in DBT of enhancing dialectical thinking
patterns to replace rigid, dichotomous thinking. The
fundamental dialectic in DBT is between validation and To overcome these difficulties, several modifications
acceptance of the client as they are within the context of were made that formed the basis of DBT. First, strategies
simultaneously helping them change. Acceptance that reflect radical acceptance and validation of clients
procedures in DBT include mindfulness (e.g., attention current capabilities and behavioral functioning were
to the present moment, assuming a non-judgmental added to the treatment. The synthesis of acceptance and
stance, focusing on effectiveness) and a variety of change within the treatment as a whole and within each
validation and acceptance-based stylistic strategies. treatment interaction led to adding the term dialectical
Change strategies in DBT include behavioral analysis of to the name of the treatment. This dialectical emphasis
maladaptive behaviors and problem-solving techniques, brings together in DBT the technologies of change
including skills training, contingency management (i.e., based on both principles of learning and crises theory
reinforcers, punishment), cognitive modification, and and the technologies of acceptance (so to speak) drawn
exposure-based strategies. from principles of eastern Zen and western
contemplative practices. Second, the therapy as a whole
As a comprehensive treatment, DBT serves the following was split into several different components, each
five functions: 1) enhances behavioral capabilities, 2) focusing on a specific aspect of treatment. The
improves motivation to change (by modifying inhibitions components in standard outpatient DBT are highly
and reinforcement contingencies), 3) assures that new structured individual or group skills training (to enhance
capabilities generalize to the natural environment, 4) capability), individual psychotherapy (addressing
structures the treatment environment in the ways motivation and skills strengthening), and telephone

Dimeff, L., & Linehan, M.M. (2001). Dialectical behavior therapy in a nutshell. The California Psychologist, 34, 10-13.
 Page 2 of 2

contact with the individual therapist (addressing centeredness (i.e., believing in oneself, the client, and the
application of coping skills). Third, a consultation/team treatment) and with compassionate flexibility (i.e., the
meeting focused specifically on keeping therapists ability to take in relevant information about the client
motivated and providing effective treatment was also and modify ones position accordingly, including the
added. ability to admit to and repair ones inevitable mistakes),
and a nurturing style (i.e., teaching, coaching, and
BEHAVIORAL TARGETS AND STAGES OF assisting the client) with a benevolently demanding
TREATMENT IN DBT approach (i.e., dragging out new behaviors from the
DBT is designed to treat clients at all levels of severity client, recognizing the clients existing capabilities and
and complexity of disorders and is conceptualized as capacity to change, having clients do for themselves
occurring in stages. In Stage 1, the primary focus is on rather than doing for them.
stabilizing the client and achieving behavioral control.
Behavioral targets in this initial stage of treatment RESEARCH IN DBT
include: decreasing life-threatening, suicidal behaviors The first DBT randomized clinical trial compared DBT
(e.g., parasuicide acts, including suicide attempts, high to a treatment-as-usual (TAU) control condition
risk suicidal ideation, plans and threats), decreasing (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991;
therapy-interfering behaviors (e.g., missing or coming Linehan, Heard, & Armstrong, 1993; Linehan, Tutek,
late to session, phoning at unreasonable hours, not Heard, & Armstrong, 1994). DBT subjects were
returning phone calls), decreasing quality-of-life significantly less likely to parasuicide during the
interfering behaviors (e.g., reducing behavioral patterns treatment year, reported fewer parasuicide episodes at
serious enough to substantially interfere with any chance each assessment point, and had less medically severe
of a reasonable quality of life (e.g., depression, substance parasuicides over the year. DBT was more effective than
dependence, homelessness, chronically unemployed), TAU at limiting treatment drop-out, the most serious
and increasing behavioral skills (e.g., skills in emotion therapy-interfering behavior. DBT subjects tended to
regulation, interpersonal effectiveness, distress tolerance, enter psychiatric units less often, had fewer inpatient
mindfulness, and self-management). In the subsequent psychiatric days per client, and improved more on scores
stages, the treatment goals are to replace quiet of global as well as social adjustment. DBT subjects
desperation with non-traumatic emotional experiencing showed significantly more improvement in reducing
[Stage 2], to achieve ordinary happiness and anger than did TAU subjects. DBT superiority was
unhappiness and reduce ongoing disorders and problems largely maintained during the one-year post-treatment
in living [Stage 3], and to resolve a sense of follow-up period. Since then, two RCTs have been
incompleteness and achieve joy [Stage 4]. In sum, the conducted evaluating DBT as compared to TAU and one
orientation of the treatment is to first get action under study has been conducted comparing DBT to an ongoing
control, then to help the client to feel better, to resolve parallel treatment with matched controls. In general,
problems in living and residual disorders, and to find joy results have largely replicated the initial RCT. Koons
and, for some, a sense of transcendence. The and her associates found that BPD women in the VA
overwhelming majority of data to date on DBT has system assigned to DBT had greater reductions in
focused on the severely and multi-disordered client who parasuicide acts and in depression scores than those
enters treatment at Stage 1. assigned to TAU and those assigned to DBT (but not to
TAU) also had significant improvements in suicide
MOVEMENT, SPEED, AND FLOW ideation, hopelessness, anger, hostility, and dissociation
DBT requires that the therapist balance use of acceptance (Koons, Robins, Tweed, Lynch, Gonzalez, Morse,
and change strategies within each treatment interaction, Bishop, Butterfield, & Bastian, in press). In our recent
from the rapid juxtaposition of change and acceptance application of DBT to substance dependent individuals
techniques to the therapist's use of both irreverent and with BPD, DBT subjects had greater reductions in illicit
warmly responsive communication styles. This dance substance use (measured by both structured interview
between change and acceptance are required to maintain and urinalyses) both during treatment and at follow-up
forward movement in the face of a client who at various and greater improvements in global functioning and
moments oscillates between suicidal crises, withdrawal social adjustment at follow-up (Linehan, et al., 1999).
and dissociative responses, rigid refusal to collaborate,
attack, rapid emotional escalation and a full collaborative REFERENCES
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