Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment developed to treat borderline personality disorder. It uses individual therapy, group skills training, telephone coaching, and a therapist consultation team. DBT aims to help patients manage emotions and impulses through mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills. Studies have found DBT reduces self-harm behaviors and improves social and work functioning for patients with borderline personality disorder.

1. Dialectical Behavior Therapy
Presenter
Dr. Dikshya Upreti
PG Resident
Moderator
Assoc. Prof. Mr Sandesh Sawant
Clinical Psychologist
National Medical College Teaching Hospital

2. Introduction
Dialectical Behavior Therapy(DBT) is a multi-modal, cognitive-
behavioral treatment originally developed to treat women who meet
criteria for Borderline Personality Disorder (BPD) with a history of
chronic self harm and suicide attempts.
DBT is an effective treatment for people who have difficulty
controlling their emotions and behaviors.

3. What Does “Dialectical” Mean?
■ Dialectical = two opposite ideas can be true at the same time,
and when considered together, can create a new truth and a
new way of viewing the situation.
■ There is always more than one way to think about a situation.

4. HISTORY
■ DBT was developed by Marsha Linehan at the University of
Washington in 1970s.
■ For years she had used standard CBT strategies to
work with suicidal and actively self-injurious patients.
■ They discovered that cognitive-behavioral therapy
alone did not work as well as expected in patients
with BPD.

5. HISTORY
■ However, Linehan found that therapists’ unrelenting focus on
trying to help patients change their problematic behaviors often
led patients to feel invalidated.
■ The first randomized controlled trial (RCT) for DBT was
published in 1991

6. DBT might be an effective treatment for:
• Attention-deficit/hyperactivity disorder
• Bipolar disorder
• Eating disorders
• Generalized anxiety disorder
• Major depressive disorder
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Substance use disorder
Kaplan and Sadock’s Synopsis of Psychiatry, 11th Edition

7. Borderline Personality Disorder (Diagnostic
Criteria according to DSM 5)
A pervasive pattern of instability of interpersonal relationships, self-
image, and affects, and marked impulsivity, beginning by early
adulthood indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships
3. Identity disturbance: markedly and persistently unstable self-image or sense
of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g.,
spending, sex, substance abuse, reckless driving, binge eating).

8. 5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability (e.g., intense episodic dysphoria, irritability, or anxiety
usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

10. ■ BPD is a severe, costly, and difficult-to-treat psychiatric disorder.
■ Most individuals diagnosed with BPD report high rates of
nonsuicidal self-injury (NSSI) and multiple suicide attempts.
■ The lifetime mortality rates by suicide are estimated to be 50 times
higher among BPD patients compared to the general population.

11. ■ According to the American Psychiatric Association there is no
single efficacious pharmacological intervention for BPD.
■ However, current practice guidelines recommend psychotherapy
as the primary treatment for BPD.
■ DBT is the psychosocial treatment that has received the most
empirical support for patients with BPD.

12. Functions of DBT
1. To enhance and expand the patient’s repertoire of skillful
behavioral patterns.
2. To improve patient motivation to change by reducing
reinforcement of maladaptive behavior.
3. To ensure that new behavioral patterns generalize from the
therapeutic to the natural environment.
4. To structure the environment so that effective behaviors, rather
than dysfunctional behaviors, are reinforced.

13. Biosocial theory of BPD
■ Invalidating environment
■ Emotional vulnerability
■ Emotional Dysregulation

14. Invalidating environment
■ It is characterized by pervasive criticizing, minimizing,
trivializing, punishing, or erratically reinforcing communication
of internal experiences (e.g., thoughts and emotions), and
oversimplifying the ease of problem solving.
■ For example, a parent may pervasively communicate
“You’re not that upset, you’re just faking it” or
“You say no, but you don’t really know what you want.”

15. Emotional vulnerability
It is defined as:
a. Heightened sensitivity
b. Heightened reactivity
c. Slow return to a baseline level of
emotional arousal

16. Emotional Dysregulation
■ An inability to readily up- or down-regulate physiological
arousal may lead to the development of extreme behavioral
dyscontrol, such as self-injurious, impulsive, and aggressive
behavior.

18. Modes of DBT
The four modes of treatment in DBT are as follows:
(1) Group skills training
(2) Individual therapy
(3) Phone consultations
(4) Consultation team

19. Group Skills Training
■ Patients learn specific behavioral, emotional, cognitive, and
interpersonal skills.
■ Unlike traditional group therapy, observations about others in the
group are discouraged.
■ Rather, a didactic approach, using specific exercises taken from a
skills training manual is used.
■ Many of which are geared toward control emotional
dysregulation and impulsive behavior.

20. A) Skills Modules: Mindfulness: It is the practice of paying attention in
a particular way: on purpose, in the present moment, and without
judgment.
B) Skills Modules: Distress Tolerance: self-injurious behavior may
function temporarily to reduce distressing emotional states.
The distress tolerance module is designed to teach patients how to
tolerate aversive emotional experiences without behaving
maladaptively.

22. C) Skills Modules: Emotion Regulation: This is designed to help
patients to better understand their emotions, reduce emotional
vulnerability, and decrease emotional suffering.
D) Skills Modules: Interpersonal Effectiveness: Patients are taught what
to say and how to say what they say depending on their priority in an
interpersonal situation.

23. Individual Therapy
■ Sessions in DBT are held weekly, generally for 50 to 60 minutes,
in which skills learned during group training are reviewed and life
events from the previous week are examined.
■ Particular attention is paid to episodes of pathological behavioral
patterns that could have been corrected if learned skills had been
put into effect.
■ Patients are encouraged to record their thoughts, feelings, and
behaviors on diary cards, which are analyzed in the session.

25. Telephone Consultation
■ Therapists are available for phone consultation 24 hours per day.
■ Patients are encouraged to call when they feel themselves
heading toward some crisis that might lead to injurious behavior
to themselves or others.
■ Calls are intended to be brief and usually last about 10 minutes.

26. Consultation Team
■ Therapists meet in weekly meetings to review their work with
their patients.
■ By doing so, they provide support for one another and maintain
motivation in their work.
■ The meetings enable them to compare techniques used and to
validate those that are most effective.

28. Consultation team agreements in DBT
1. Meet weekly for 1–2 hours
2. Discuss cases according to the treatment hierarchy (i.e., self-injurious/life-
threatening behavior, treatment-interfering behavior, and quality-of-life–interfering
behavior)
3. Accept a dialectical philosophy
4. Consult with the patient on how to interact with other therapists, and do not tell
other therapists how to interact with the patient

29. Consultation Team Agreements in Dialectical
Behavior Therapy
5. Do not expect consistency of therapists with one another (even across
the same patient)
6. Allow all therapists observe own limits without fear of judgmental
reactions from other consultation group members
7. Search for nonpejorative, empathic interpretation of patient’s behavior
8. Acknowledge that all therapists are fallible

30. RESULTS
 Several studies evaluating the effect of DBT for patients with BPD
found that such therapy was positive.
 Patients had a low dropout rate from treatment
 The incidence of parasuicidal behaviors declined
 Self-report of angry affect decreased
 Social adjustment and work performance improved

31. References:
• Kaplan and Sadock’s Synopsis of Psychiatry, 11th Edition
• Kaplan and Sadock’s Comprehensive textbook of psychiatry, 10th
Edition