Dialectical behavior therapy

Why it was needed1

Standard CBT in the late 1970s failed chronically suicidal clients; many felt criticised and invalidated by a pure focus on change.

Biosocial theory1

A biological tendency to intense emotion meets an invalidating environment, and emotion dysregulation follows.

Acceptance and change1

The therapist validates the client's feelings while showing that some behaviours do not work and teaching better ones.

Wise mind1

Mindfulness skills aim at a 'wise mind', the synthesis of rational mind and emotional mind.

Changing temperature (TIPP)7

In a published case, the client's plan for moments of intense anger included crisis survival skills such as changing her body temperature with an ice pack.

What TIPP is not8

TIPP stands for temperature, intense exercise, paced breathing and paired muscle relaxation. Walking slowly and leisurely does not count as its intense exercise, which aims to raise the heart rate.

Opposite action7

The same client practised acting opposite to anger: instead of insulting her parents, trying to put herself in their place.

DEAR MAN9

Illustration: asking a flatmate to wash up, someone Describes the facts ("the dishes have been in the sink since Monday"), Expresses how they feel, Asserts the request, Reinforces ("evenings would be easier for both of us"), stays Mindful of the goal, Appears confident and Negotiates.

Distraction8

In a DBT skills group for mothers, one example of distraction was playing loud music during a stressful moment; another was using distraction when the urge to yell at a child came up.

Chain analysis7

A binge was traced back link by link: irregular sleep and meals, then emptiness, loneliness and anger, the thought "she will always be fat, not worthy", then aggressively asking her parents to buy food; relief came first, isolation and self-judgement later.

Validation7

The therapist said: "…it makes sense that you felt lonely when your parents left and frustrated for not being able to go to your uncle's lunch."

Finding the middle path7

Instead of the two extremes, staying home or going to the family lunch and bingeing, the therapist suggested a synthesis: go, and bring her own food.

Wise mind, in a client's words10

"I can get myself into wise mind and use the skills. And then if I need to blow off steam, I can just go through the skills and pick out the ones to calm myself down."

Individual therapy2

Weekly sessions build motivation and help apply skills to the client's real problems.

Skills group3

Taught like a class, about 2.5 hours a week, with homework.

Phone coaching2

Clients call their therapist between sessions for help using skills in the moment.

Consultation team2

Therapists support each other to stay faithful to the treatment and motivated with high-risk clients.

Diary cards and chain analysis1

Daily cards track emotions and behaviours; chain analysis traces the events, thoughts and feelings that led to a problem behaviour.

Mindfulness3

Staying aware and present, without judgement.

Distress tolerance3

Getting through painful moments without making them worse, including Radical acceptance.

Emotion regulation3

Understanding emotions, lowering vulnerability to unwanted ones and changing them, for example by opposite action.

Interpersonal effectiveness3

Asking for what you need and saying no while keeping relationships and self-respect.

First trial (1991)4

In a one-year randomized trial, chronically parasuicidal women with BPD in DBT had fewer incidents of parasuicide than with treatment as usual.

Cochrane review (2020)5

Compared to usual care, DBT reduced BPD severity and self-harm and improved functioning, but on low-quality evidence.

Not a universal cure1

An adapted DBT skills programme in schools showed null or harmful effects, though most students barely engaged.

Costs and time1

Critics note it demands a lot of time, and that for complex PTSD it may not beat standard PTSD treatments.

Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993)6

Linehan's treatment manual.

DBT Skills Training Manual (2015)6

The skills curriculum, with a companion book of handouts and worksheets.

Building a Life Worth Living (2020)6

Linehan's memoir of her own illness and the making of DBT.