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The Evolution and Impact of Dialectical Behavior Therapy in Mental Health

Dialectical Behavior Therapy (DBT) is a comprehensive cognitive-behavioral treatment that has revolutionized the field of psychotherapy since its development. Created by psychologist Marsha M. Linehan in the late 1980s, DBT was initially designed to treat individuals with borderline personality disorder (BPD) and chronic suicidal ideation (Linehan, 1993). It has since evolved to address a range of mental health disorders, proving to be an effective treatment modality.


DBT stands out for its unique blend of acceptance and change strategies, combining standard cognitive-behavioral techniques with concepts derived from Eastern mindfulness practices. This therapy emphasizes the development of skills in four key areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. These skills empower individuals to manage their emotions more effectively, cope with stress in a healthy manner, and improve their relationships.


The significance of DBT in modern psychotherapy cannot be overstated. It has been a game-changer, particularly for individuals with complex emotional and behavioral issues for whom other treatments have been ineffective. DBT's evidence-based approach and its adaptability to treat a variety of mental health conditions have made it a cornerstone in contemporary therapeutic practices.


The Development of DBT 

The development of Dialectical Behavior Therapy (DBT) is a testament to the innovative work of psychologist Marsha Linehan. In the late 1980s, Linehan, grappling with the challenges of treating individuals with borderline personality disorder (BPD) and suicidal behaviors, developed DBT as a response to the limitations of existing therapies (Linehan, 2015). Her approach was revolutionary, as it combined the cognitive-behavioral techniques with new methods drawn from Eastern mindfulness practices.


Linehan's development of DBT was influenced by her own experiences and observations in clinical settings. She noticed that conventional cognitive-behavioral approaches, while effective in treating a range of disorders, were not fully addressing the needs of clients with BPD, particularly those exhibiting self-harm behaviors and extreme emotional dysregulation. DBT was born out of the need for a therapy that could embrace both acceptance and change – a dialectical philosophy that acknowledges and validates clients' experiences while simultaneously guiding them towards positive change.


The theoretical underpinnings of DBT are rooted in the concept of dialectics, which emphasizes the synthesis of opposites, a core principle that underlies the entire structure of DBT. This approach helps clients learn to balance acceptance of their current situation with the effort to change unwanted behaviors and thoughts. Additionally, mindfulness, derived from Buddhist practices, plays a crucial role in DBT, teaching clients to be present in the moment and develop an awareness of their thoughts and feelings without judgment.


Linehan's DBT Skills Training Manual, Second Edition, provides an in-depth look into the development and application of these skills, offering a comprehensive guide for therapists and clients alike in navigating this complex and effective therapy.


Research Base of DBT 

Dialectical Behavior Therapy (DBT) has a robust research base that underscores its efficacy across various mental health conditions. Numerous studies have demonstrated DBT's effectiveness, particularly in treating borderline personality disorder (BPD), suicidal ideation, and self-harming behaviors. Koerner (2012) highlights the significant impact of DBT in reducing suicidal and self-injurious behaviors in individuals with BPD, a finding echoed in multiple clinical trials and research studies.


One landmark study by Linehan et al. (2006) compared DBT with treatment-as-usual (TAU) for individuals with BPD and chronic suicidal behaviors. The results indicated that DBT was more effective in reducing suicidal behavior, psychiatric hospitalizations, and treatment dropouts. This study was pivotal in establishing DBT as a preferred treatment for BPD.


DBT's efficacy extends beyond BPD. Research has shown its effectiveness in treating substance use disorders, eating disorders, and post-traumatic stress disorder (PTSD). For instance, a study by Dimeff and Linehan (2008) demonstrated that DBT could significantly reduce substance abuse in individuals with BPD, offering a more effective treatment approach than standard substance abuse therapies.


When compared with other therapeutic models, DBT stands out for its unique approach to managing emotional dysregulation, a core feature of many psychological disorders. Unlike traditional cognitive-behavioral therapy (CBT), which focuses primarily on changing negative thought patterns, DBT emphasizes the balance between acceptance and change. This dialectical approach, combined with its focus on skill-building in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, makes DBT particularly effective for individuals who struggle with intense emotional responses and impulsive behaviors.


DBT's structured nature, with its clear stages and goals, provides a framework that can be more conducive to progress for certain clients compared to less structured therapies. The incorporation of both individual therapy and group skills training in DBT also offers a comprehensive approach that addresses a wide range of client needs.


The research base for DBT demonstrates its effectiveness and versatility as a therapeutic model, making it a valuable tool in the treatment of a variety of mental health disorders.


DBT and Trauma   

Dialectical Behavior Therapy (DBT) has been effectively adapted to treat individuals experiencing trauma, particularly those with complex trauma histories and post-traumatic stress disorder (PTSD). Harned, Korslund, and Linehan's study (2014) is a significant contribution to this field, demonstrating the efficacy of DBT in treating trauma-related symptoms, especially in cases where trauma is intertwined with self-harm and suicidal behaviors.


DBT for trauma incorporates standard DBT skills with specific techniques to address trauma. One such technique is the DBT Prolonged Exposure (DBT-PE) protocol, which integrates exposure therapy into the DBT framework. This approach involves gradually exposing clients to trauma-related memories and stimuli, helping them process and desensitize these experiences in a safe and controlled environment. The goal is to reduce trauma-induced emotional and behavioral responses, thereby diminishing the power of traumatic memories.


The outcomes of DBT in treating trauma have been promising. Harned et al.'s study (2014) showed that participants receiving DBT with the DBT-PE protocol exhibited significant reductions in PTSD symptoms, self-harm, and suicidal ideation compared to those receiving DBT alone. This suggests that integrating trauma-specific treatment within the DBT framework enhances its effectiveness for individuals with complex trauma.


Case studies further illustrate the impact of DBT in treating trauma. For instance, a client with a history of childhood abuse and subsequent PTSD symptoms might engage in DBT to learn skills for managing intense emotions and reducing self-harm behaviors. Through the DBT-PE protocol, the client can confront and process traumatic memories, leading to a significant reduction in PTSD symptoms and an improvement in overall functioning.


DBT's application in treating trauma, particularly when combined with the DBT-PE protocol, offers a comprehensive approach that addresses both the symptoms of PTSD and the underlying emotional dysregulation often associated with trauma. This dual focus makes DBT a particularly effective treatment for individuals with complex trauma histories.


DBT and Substance Use Disorders 

Dialectical Behavior Therapy (DBT) has been adapted to effectively treat substance use disorders (SUDs), particularly among individuals with co-occurring borderline personality disorder (BPD). Linehan et al. (1999) conducted a pioneering study that demonstrated the efficacy of DBT in treating patients with BPD and drug dependence. This study marked a significant advancement in understanding how DBT can be tailored to address the complex needs of individuals struggling with both emotional dysregulation and substance abuse.


DBT's approach to SUDs involves targeting behaviors associated with substance abuse directly while simultaneously addressing the underlying emotional and psychological issues. The therapy integrates techniques for enhancing motivation, developing coping skills to avoid substance use, and managing triggers for relapse. A key component of DBT for SUDs is its emphasis on developing mindfulness skills, which help clients become more aware of their thoughts, feelings, and urges related to substance use. Clients are also taught distress tolerance skills to better handle emotional discomfort without resorting to substance use.


The effectiveness of DBT in treating SUDs is evident in its ability to reduce substance abuse behaviors and improve emotional regulation. Linehan et al.'s study found that participants receiving DBT showed significant reductions in drug use and were more likely to stay in treatment compared to those receiving standard treatment. Additionally, clients in DBT reported improvements in managing emotions and stress, factors often contributing to substance use.


Client experiences in DBT for SUDs have been positive, with many reporting a greater sense of control over their substance use and an improved quality of life. The skills learned in DBT, such as mindfulness and emotional regulation, not only aid in recovery from substance abuse but also enhance overall well-being.


In summary, DBT offers a comprehensive and effective approach for treating substance use disorders, particularly when they co-occur with borderline personality disorder. Its focus on both behavior change and emotional healing makes it a valuable tool in the treatment of SUDs.


DBT and Anxiety Disorders 

Dialectical Behavior Therapy (DBT) has been increasingly recognized for its effectiveness in treating anxiety disorders, particularly where these disorders are characterized by emotion dysregulation. Neacsiu et al. (2014) conducted a study that highlights DBT's applicability beyond its original scope of borderline personality disorder, demonstrating its efficacy in addressing transdiagnostic emotion dysregulation, a core component of various anxiety disorders.


DBT addresses anxiety disorders by focusing on the development of skills in four key areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Mindfulness practices in DBT help individuals with anxiety to become more aware of their present-moment experiences, reducing rumination and worry. Distress tolerance skills are particularly beneficial in managing acute anxiety symptoms, teaching clients how to tolerate and survive anxiety-provoking situations without resorting to maladaptive coping strategies.


Emotion regulation skills are central to DBT's effectiveness with anxiety disorders. These skills help individuals understand and label their emotions, decrease the intensity of unwanted emotions, and increase resilience to emotional triggers. Interpersonal effectiveness skills, meanwhile, assist clients in navigating relationships more effectively, reducing anxiety around interpersonal interactions.


Neacsiu et al.'s study (2014) supports the effectiveness of these techniques, showing that participants who underwent DBT skills training experienced significant improvements in emotion regulation and reductions in anxiety symptoms. This study underscores DBT's potential as a versatile treatment modality, capable of addressing the complex needs of individuals with various anxiety disorders.



DBT and Eating Disorders 

Dialectical Behavior Therapy (DBT) has shown significant promise in treating eating disorders, particularly binge eating disorder (BED) and bulimia nervosa (BN). Safer, Telch, and Chen's work (2009) provides a comprehensive overview of how DBT has been adapted to meet the unique needs of individuals struggling with these conditions. 


DBT's application to eating disorders is grounded in its ability to address the emotional dysregulation often underlying disordered eating behaviors. Individuals with eating disorders typically experience intense and fluctuating emotions, which they may attempt to manage or suppress through unhealthy eating behaviors. DBT equips them with healthier skills to regulate these emotions, reducing the reliance on disordered eating as a coping mechanism.


One of the key strategies in DBT for eating disorders is mindfulness, which helps clients become more aware of their eating patterns, prompting events for binge eating or purging, and the accompanying emotional states. Mindfulness practices encourage a non-judgmental stance towards food and body image, fostering a healthier relationship with both.


Distress tolerance skills are particularly crucial, as they enable individuals to withstand urges to binge or purge without acting on them. These skills help in breaking the cycle of emotional eating and impulsive behaviors associated with BED and BN.


Emotion regulation skills in DBT teach clients how to identify, understand, and manage their emotions effectively. This is vital in addressing the mood swings and emotional triggers that often lead to disordered eating patterns.


Interpersonal effectiveness skills are also a component of DBT for eating disorders. These skills assist individuals in navigating interpersonal conflicts and stressors that may contribute to their eating disorder.


The effectiveness of DBT in treating eating disorders has been supported by research. Safer et al. (2009) found that DBT led to significant reductions in binge eating and purging behaviors, as well as improvements in emotional regulation. This highlights DBT's potential as a comprehensive treatment approach for eating disorders, addressing both the behavioral and emotional aspects of these complex conditions.


Overview of DBT Modules and Diary Cards

Dialectical Behavior Therapy (DBT) is structured around four core modules, each designed to develop specific skills that contribute to the overall effectiveness of the therapy. Linehan's "DBT Skills Training Handouts and Worksheets, Second Edition" (2015) provides a detailed guide to these modules.


1. Mindfulness: The foundation of all skills taught in DBT, mindfulness focuses on developing an awareness of the present moment in a non-judgmental way. It helps clients to observe and describe their thoughts, feelings, and sensations without reacting to them automatically. This skill is crucial for clients to gain control over their emotions and actions.


2. Distress Tolerance: This module teaches clients how to tolerate and survive crises without resorting to self-destructive behaviors. It includes skills like distraction, self-soothing, and improving the moment, which are essential for managing intense emotional situations.


3. Emotion Regulation: Emotion regulation skills help clients understand and manage their emotions effectively. This module includes techniques for identifying and labeling emotions, increasing positive emotional events, and decreasing vulnerability to emotion mind.


4. Interpersonal Effectiveness: This module focuses on improving relationships and communication skills. It teaches clients how to assert their needs and manage conflict in relationships in a way that is assertive but not aggressive, maintaining self-respect and relationships with others.


Diary cards are a vital component of DBT, serving as a daily tracking tool for clients. They record a variety of behaviors, emotions, and skill use, providing both the client and therapist with valuable information. Diary cards help in identifying patterns in behavior and emotion, tracking progress, and guiding therapy sessions. They are particularly useful for monitoring problematic behaviors, such as self-harm or substance use, and for reinforcing the application of DBT skills in daily life.


The integration of these modules, along with the use of diary cards, makes DBT a comprehensive and effective approach for treating a range of psychological disorders, providing clients with practical skills for managing their emotions, behaviors, and relationships.


Differentiating DBT-Informed and Comprehensive DBT 

Understanding the distinction between DBT-Informed and Comprehensive DBT is crucial for both practitioners and clients seeking therapy. As outlined by Swales and Heard (2017), these two approaches, while rooted in the same foundational principles, differ significantly in their structure and application.


DBT-Informed therapy refers to an approach where only specific elements or skills of the DBT model are incorporated into treatment. This often includes the use of DBT skills training – mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness – without the full array of DBT components. DBT-Informed therapy can be beneficial in settings where resources or time are limited, or when clients may not require the full intensity of comprehensive DBT. It allows for the integration of DBT skills into other therapeutic approaches, providing clients with valuable tools for managing emotions and behaviors.


Comprehensive DBT, on the other hand, is a more intensive treatment that includes all aspects of the standard DBT model. This includes individual therapy, skills training group, phone coaching, and therapist consultation team. Comprehensive DBT is designed for individuals with more complex or severe disorders, particularly those with high-risk behaviors such as self-harm or suicidal ideation. The full model ensures that clients receive consistent, multifaceted support, addressing their needs from various angles for more effective treatment outcomes.


Both DBT-Informed and Comprehensive DBT have their place in therapeutic settings, and the choice between them depends on the specific needs and circumstances of the client. Understanding these differences allows therapists to tailor their approach to provide the most effective treatment for each individual.


In Summary

Dialectical Behavior Therapy (DBT) has established itself as a significant and versatile treatment modality in the field of psychotherapy. Its efficacy in treating a range of disorders, particularly those characterized by emotion dysregulation such as borderline personality disorder, eating disorders, substance use disorders, and anxiety disorders, has been well-documented in various studies (Linehan, 1993; Safer et al., 2009; Neacsiu et al., 2014). The comprehensive nature of DBT, with its unique blend of cognitive-behavioral techniques and mindfulness principles, equips clients with practical skills to manage their emotions, improve their relationships, and make meaningful changes in their lives.


Looking to the future, the potential of DBT continues to expand. Ongoing research is exploring its applicability to a broader range of psychological issues, including complex trauma and mood disorders. There is also a growing interest in adapting DBT for diverse populations and settings, such as adolescents, schools, and online platforms. The flexibility of the DBT framework allows for these adaptations while maintaining the core components that make the therapy effective.


The increasing integration of technology in therapy presents new opportunities for DBT. Digital tools and online resources can make DBT skills more accessible, supporting clients in their day-to-day application of the techniques learned in therapy. As the field of psychotherapy continues to evolve, DBT is well-positioned to remain at the forefront, offering effective, evidence-based treatment to those in need.


In conclusion, DBT's significance in the treatment of various psychological disorders is well-established, and its future in the evolving landscape of mental health treatment looks promising. Its adaptability, effectiveness, and comprehensive approach make it a valuable asset in psychotherapy.


References and Further Reading 

Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged 

Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy, 55, 7-17.


Koerner, K. (2012). Doing Dialectical Behavior Therapy: A Practical Guide. Guilford Press.


Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.


Linehan, M. M. (2015). DBT Skills Training Manual, Second Edition. Guilford Press.


Linehan, M. M. (2015). DBT Skills Training Handouts and Worksheets, Second Edition. Guilford Press.


Linehan, M. M., Schmidt, H., Dimeff, L. A., et al. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. The American Journal on Addictions, 8(4), 279-292.


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