Dialectical behavior therapy: What is it and how is it different?

Dialectical behavior therapy includes mindfulness-based activities and skill training for treatment

Arathi Kannan

In 1961, a 17-year-old was admitted to a psychiatric facility in Connecticut, USA for extreme social withdrawal and habitually harming herself. While the records described her as “one of the most disturbed patients in the hospital,” she herself recounts her time spent in a seclusion room for severely ill patients as “hell.

This young girl was Dr Marsha Linehan, pioneer of  dialectical behavior therapy (DBT). In 2011, Dr Linehan publicly spoke about her journey for the first time. A New York Times article carried the story of her battle with mental health and the path to recovery – her illness, the lack of an accurate diagnosis – and treatment that inspired her to develop a therapeutic intervention.

Dr Linehan believes she would have been diagnosed with borderline personality disorder (BPD) had it been known then. Today, BPD is one of the most commonly diagnosed personality disorders. There are several people with similar journeys of complex diagnoses and mismanagement who have found DBT helpful in managing their symptoms.

What is DBT?   

DBT is a form of talk therapy that was modified from the existing practice of behavior therapy. Its main aim is to help clients live a ‘life worth living’ by treating people who face difficulties in regulating emotions – it encourages them to solve their problems. It focuses on skills training to equip clients with tools to effectively cope with their issues. DBT also helps them create long-term goals and work towards it. 

Application of DBT for various mental illnesses

DBT was initially developed to treat BPD. In 1991, Dr Linehan and her team conducted a study on the treatment of women with BPD and parasuicidal ideation (suicidal gesture where the aim is not death). It was found to be a useful mode of treatment to reduce self-harming behaviors and increase attendance at therapy.

Over time, DBT has been evolved to address a variety of other clinical conditions. These include eating disorders, anger management, some aspects of attention-deficit/hyperactivity disorder (ADHD), depression, and post-traumatic stress disorder (PTSD). In such instances, DBT targets different aspects of the illness – it aims to enhance coping mechanisms such as interpersonal skills (like assertiveness), mindfulness skills, emotional regulation, delaying gratification and impulse responses (like for binge eating and substance use disorders).

Like cognitive behavioral therapy (CBT), action plans (or, home assignments) form a part of DBT treatment. Here the clients are given tasks to complete between sessions that will aid in their progress. Clients seeking DBT often have trouble with interpersonal relationships; it is crucial for both the client and the therapist to form a strong therapeutic relationship to experience progress in the treatment process.

What is the difference between DBT and CBT?

The two forms of talk therapies vary in their primary focus and some of their core components.

CBT focuses on the modification of a client’s dysfunctional thoughts and behaviors. DBT — in addition to change —  focuses on acceptance of all feelings that accompany the illness. DBT practitioners believe recognition, acceptance and understanding of one’s experiences, thoughts and emotions can help them deal with their problems in a different way. It aims to strike a balance between acceptance and change.

Both CBT and DBT use therapeutic strategies to treat clients. CBT involves various forms of anxiety and arousal management techniques. On the other hand, mindfulness-based interventions form one of the core components of DBT which is absent from conventional CBT practices.

What constitutes a typical DBT treatment plan?

Primary modes of treatment delivery for DBT are individual therapy, group skills training, and skills coaching in between sessions.

Individual sessions help the therapist build a rapport with the client. These sessions also involve setting limits on when the sessions are to be held and teaching them skills for specific challenges that occur in their daily life. The therapist also motivates the clients to work on their problems.

Skills coaching is where the clients learn different skills that enhance their ability to manage emotions and get closer to improving themselves. These include mindfulness, becoming aware of one’s emotions and identifying them, addressing expressions of self-harm, independently dealing with a crisis, and communicating in relationships (expressing requests/refusals using role plays with the therapist). These sessions are held routinely as skill deficits are best addressed with regular practice.

Clients are  encouraged to contact the therapist if they find themselves in a crisis and require immediate skills coaching. Limits to when the client can contact the therapist are discussed during sessions.

This article has been written with inputs from Dr Paulomi Sudhir, clinical psychologist at NIMHANS.

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