Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment developed by Marsha Linehan to address borderline personality disorder (BPD) and chronic self-harm. DBT integrates acceptance and change strategies and has shown empirical support for treating parasuicidal behavior, substance use disorders, and eating disorders among other conditions. The therapy involves individual and group sessions focusing on skill modules such as mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness.

1. Dialectical behavior therapy
Prepared by: Dr Prabidhi Adhikari
Moderator: Assoc. Prof. Dr Tanveer Ahmed Khan

2. Contents
• Introduction
• Goals
• Function
• Indication
• Research evidences
• Modules
• References

3. Introduction
• DBT is a multimodal cognitive behavioral treatment originally
developed to treat women who meet the criteria of BPD with
history of chronic self harm and suicidal attempts.
• Was developed in the 1980s by the American psychologist Marsha
Linehan, who viewed standard CBT as insufficient for treating
chronic self-harm and suicidal behaviors, such as those stemming
from borderline personality disorder(BPD)
• DBT was a trial-and-error clinical effort based on the application of
behavioral principles (Bandura, 1969) and social learning theory
(Staats & Staats, 1963; Staats, 1975) to suicidal behaviors (Linehan,
1981).

4. Introduction
• Marsha added the concept of validation and dialectics to CBT.
• In the first randomized controlled trial (RCT) in 1991 , Linehan and colleagues
actively recruited the most severe, highly suicidal clients from local area
hospitals (Linehan et al., 1991)
• The first complete draft of the treatment manual focused primarily on
ameliorating suicidal behaviors; however, federal grant funding required that
treatment outcome research identify a mental disorder diagnosis.

5. Introduction
• As a result, the first clinical trials conducted were focused on treating
chronically suicidal who also met criteria for borderline personality disorder
(BPD), a population known for being at risk for suicide (Leichsenring, Leibing,
Kruse, New, & Leweke, 2011)
• Behavioral Tech (behavioraltech.org) and the Linehan Institute are her
research, treatment, and training entities
• Revised/updated skills training manual published November 2014
• Additional research has been conducted on DBT with teens, families, people
with substance abuse, the depressed elderly, and those with eating
disorders.

6. CBT was less successful in BPD
• Clients found unrelenting focus on change invalidating.
• Clients unintentionally positively reinforced their therapists for ineffective
treatment, while punishing for effective therapy.
• The volume and severity of problem made it impossible to use CBT

7. Goal
• The goal of DBT is to change the behavior causing suffering our lives and
simultaneously accepting ourselves and our circumstances in this moment.
• By weaving acceptance and change dialectics come in play.
• The ultimate goal of DBT is to help person have a “life worth living”.

8. Function
(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, including dysfunctional cognition and emotion.
(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.
(5) To enhance the motivation and capabilities of the therapist so that the treatment
rendered is effective.
(CTP-10th edition)

9. Useful for treatment of
BPD
ADHD
Bipolar
disorder
Eating
disorder
Generalized
anxiety
disorder
Major
depressive
disorder
OCD
PTSD
Substance
use
disorder
(Kaplan and
Sadock's )

10. When to use DBT?(Research evidence)
• The patient populations for which DBT has the most empirical support include
parasuicidal women with borderline personality disorder (BPD), but there have
been promising findings for patients with BPD and substance use disorders
(SUDs), persons who meet criteria for binge-eating disorder, and depressed
elderly patients. (Linehan MM, Comtois KA, Murray AM, et al.)
• The first study in this area compared DBT to TAU for women who met criteria for
BPD and SUD.
• DBT patients showed greater reductions in drug use during the 12-month
treatment and through the four-month follow up period and had lower drop out
rates during treatment.

11. • For parasuicidal BPD patients, the most consistent finding is that DBT results in
superior reductions in parasuicidal behavior compared with control conditions.
• The first RCT of DBT (N=44 parasuicidal women with BPD) found that DBT
outperformed treatment-as-usual in reducing the frequency and medical
severity of parasuicide, inpatient hospitalization days, trait anger, and social
functioning.(Linehan MM, Armstrong HE, Suarez A, et al.)

12. • Telch and colleagues compared a 20-week DBT-based skills training group to a
wait list control condition for women with binge-eating disorder and found that
DBT patients had greater improvements in bingeing, body image, eating
concerns, and anger. (Telch CF, Agras WS, Linehan MM.)
• In a study of depressed elderly patients who met criteria for a personality
disorder investigators compared an adapted version of DBT plus antidepressant
medications to medications only.
• Findings indicated that a larger proportion of DBT patients were in remission
from depression at post-treatment and at the six-month follow-up period.(Lynch
TR, Morse JQ, Mendelson T, et al.)

13. Borderline personality disorder(BPD)
“That BPD is primarily a dysfunction of the emotion regulation system; it results from
biological irregularities combined with certain dysfunctional environments, as well as
from their interaction and transaction over time.” (Linehan, 1993)
Dialectical behavior therapy aims to address the symptoms of BPD by replacing
maladaptive behaviors with healthier coping skills.
It is currently the only empirically supported treatment for BPD as demonstrated by
the Cochrane Collaborative Review. (Stoffers JM, Völlm BA, Rücker G, Timmer A,
Huband N, Lieb K. )
NICE has published guidelines that medication should not be used specifically for BPD
or symptoms associated with BPD (SH, emotional instability).

14. DSM-5

15. Symptoms of Borderline
Personality Disorder
Emotion
Dysregulation
•Unstable
Emotions/Mood
•Intense
Anger/Difficulty
Controlling
Anger
Interpersonal
Dysregulation
•Unstable/Intense
Relationships
•Frantic Efforts
to Avoid
Abandonment
Behavioural
Dysregulation
•Impulsive/Self-
Damaging
Behaviours
•Suicide/Self-
harm
Identity/Self
Dysregulation
•Unstable Sense
of Self/Identity
•Feelings of
Emptiness
Cognitive
Dysregulation
•Stress Related
Paranoid
Thoughts
•Dissociation

16. Biosocial theory of BPD

17. Emotional vulnarability
• High emotional sensitivity
-Immediate reaction
-Low threshold for emotional reaction
• High emotional reactivity
-Extreme reaction
-High arousal dysregulate cognitive processing
• Slow return to base line
-Long lasting reaction
-Contributes to high sensitivity to next emotional stimulus

18. Invalidating environment
• “An invalidating environment is one in which communication of private experiences is met
by erratic, inappropriate, and extreme responses.
• The expression of private experiences is not validated; instead, it is often punished and/or
trivialized.
• The experience of painful emotions, as well as the factors related to the emotional distress,
are disregarded.
• The individual’s interpretations of her own behavior, including intents and motivations
associated with the behavior, are dismissed.”
(Marsha Linehan, Ph.D., 1993)

19. • Characterized by pervasive criticizing, minimizing, trivializing, punishing or
erratically reinforcing communication of internal environment (e.g., thoughts and
emotions ) and oversimplifying the ease of problem solving.
• When your emotions are repeatedly invalidated, you learn to mistrust your feelings
and to judge them as bad or wrong.
• You also learned to escalate or intensify your emotions to get help because you got
the message growing up that unless you get really upset or really angry, others
won’t respond to you.
• Consciously or unconsciously, directly or indirectly, partnerships, families, schools,
companies, workplaces, communities – even entire nations – can create
invalidating environments.

20. Little
tolerance for
a child’s
private
emotions.
“You’re the
only who is so
upset over
this, so stop
crying.“
Inconsistently
responding to
extreme
emotions,
while at the
same time
communicating
to the child
that those
emotions are
inappropriate.
Such as
ignoring a
child’s crying
when they hurt
themselves –
until the
cries bother
the adult so
much that the
adult responds
in a shaming
or cold way.
“Stop being
such a baby!”
or “What’s
wrong with
you? Pull
yourself
together.”
Telling a
child that
some emotions
are wrong, bad
or stupid.
“What a dumb
thing to get
upset over!”
Sending the
message that
emotions
should be
dealt with
alone. “Don’t
come out of
your room
until you calm
down!”
an emotion but
not helping a
child deal
with the
emotion when
help is
needed. “I see
you are upset
that your pet
rabbit is
missing,” but
doing nothing
to help the
child look for
the missing
pet.

21. Emotional dysregulation
• An inability to readily up or down
regulate physiological arousal may
lead to development of extreme
behavioral uncontrol, such self-
injurious, impulsive and aggressive
behavior.

22. Dialectical :
• Two opposite idea that can be true at the same time, and when considered together, can
create a new truth and a new way of viewing situation.
• There is more than one way of thinking.
• The tension between two opposites, e.g., acceptance and change
Behavior: DBT teaches people skills they need and may not have, to help them live more
effectively
Therapy: Treatment is both individual, with a DBT-trained therapist, and group, in a weekly
skills class.

25. DBT assumptions

26. Agreement of clients Agreement of therapists
• Stay in therapy for (1
year).
• Attend all therapy
sessions
• If 4 consecutive sessions
are missed –therapy will
be discontinued.
• Work towards terminating
deliberate self harm
behaviors.
• Participate in skill
training.
• Payment
• Maintain competence
• Provide professional
treatment
• Available for weekly
consultation
• Available for telephone
consultation
• Maintain confidentiality
• Attend DBT consultation
team
• Treat patient with respect
and humanly
• Abide by DBT consultation
team advice

27. Modes/Techniques of DBT
• Group skill training
• Individual therapy
• Phone consultation
• Consultation team
• It takes about 6 months to complete all the modules.
• Individuals can choose to repeat the modules.
• It is recommended that patients who are new to DBT stay in the skills training group
for at least 1 year.
Sessions Time
weekly individual therapy approximately 1 hour
weekly group skills training session approximately 1.5–2.5 hours
therapist consultation team meeting approximately 1–2 hours

28. Group skill training
• In group format, patients learn specific behavioral, emotional, cognitive, and
interpersonal skills not learned earlier in life.
• Primary function is acquisition of new coping skills.
• Emotional arousal during group provides natural opportunities for skills practice.
• Occurs in weekly basis.
• Typically lasts 2 hours
• Includes 4 to 10 members
• Two DBT trained co-leaders.
• Group may be:
- Homogeneous / heterogeneous
First hour Second hour
Brief mindfulness
practice
Homework review
New skills are
taught didactically
from skill trained
manual.

29. Skill modules

30. Skill modules : mindfulness
• Mindfulness is the practice of paying attention in particular way :on purpose, in
present moment and without judgement.
• Mindfulness is considered the core set of skills in DBT.
• Derived from eastern meditative and Christian contemplative traditions.
• Patients learn that their behavior is the function of current emotions and logical
analysis.
• “Wise mind” relates to the synthesis between emotional and logical thinking such
that coping decision are both effective and remain within personal values but do not
need to be free of all emotions.

31. Skill modules : mindfulness
• Effectiveness refers to behaving in a way that is consistent with one’s values and
long-term goals ,and not immediately reducing distress despite adverse
consequences.
• Effectiveness is the key aspect of mindfulness.

32. Skill modules : Distress tolerance
• Patient with BPD frequently experience emotional distress.
• Many symptoms may develop as a means of reducing chronic and intense
distress, albeit in maladaptive fashion.
• E.g: self-injurious behavior reduce –distressing emotional states
• Teach patients how to tolerate aversive emotional experiences without behaving
maladaptively.
• A list of crisis management skills is taught, including strategies for effective
temporary distraction.

33. Distraction
Activities:
• Refocus your attention on the task you have to get done
• TV, events, exercise, internet, sports, hobbies
Contributing:
• Volunteering, help a friend, encourage someone
Comparisons:
• Compare how you are feeling now to a time when you felt different
Different Emotions:
• Books, stories, movies, music
Pushing Away:
• Leave the situation; block thoughts from your mind
Other Thoughts:
• Counting; puzzles
Other Sensations:
• Squeeze a rubber ball; hold ice; go out in the rain

34. Imaginal and relaxation exercises
• Starting with your hands, moving to your forearms, upper arms, shoulders, neck,
forehead, eyes, cheeks & lips, tongue & jaw, chest, upper back, stomach, buttocks,
thighs, calves, ankles, feet.
• TENSE (5 seconds), then let go and RELAX each muscle (all the way).
Breathing exercises
• Slow your pace of inhaling and exhaling way down (on average 5 to 7 breath cycles per
minute).
• Breathe deeply from the abdomen.
• Breathe more slowly out than when breathing in (for example, 4 seconds in and 8
seconds out).

35. Self-Soothing
Vision:
• Stars at night; pictures in a book, nature, candles
Hearing:
• Soothing music; invigorating music; sounds of nature; sounds of the city
Smell:
• Soap, incense, coffee, essential oils, boil cinnamon
Taste:
• Favorite foods; soothing drinks; chew gum
Touch:
• Hot baths; pet your dog or cat; creamy lotion; comfortable clothing

36. STOP Skills
Stop
Do not just react. Your emotions may try to make you act without thinking. Stay in
control!
Take a step back
Take a step back from the situation. Let go. Do not let your feelings put you over the edge
and make you act impulsively.
Observe
Take notice of what is going on inside and outside of yourself. What is the
situation? What are your thoughts and feelings? What are others saying or doing?
Proceed mindfully
Act with awareness. Think about your goals. What do you want to get from this situation?
Which actions will make it better or worse?

37. Skill modules: Emotional regulation
• Designed to help patients to better understand their emotions, reduce emotional
vulnerability and decrease emotional suffering.
Skills include:
• increasing awareness of emotions
• identifying and challenging distorted ways of thinking about emotions
• learning how emotions are related to the problem behaviors
• accurately labeling emotions
• reducing emotional vulnerability
• increasing pleasant emotions
• acting opposite to behavioral urges to emotions

38. Model of Emotion: Observe and
Describe Emotions
Prompting Event: What set off the emotion?
Emotion: i.e., anger, fear, joy
Interpretations: Thoughts, judgments, beliefs
Experiencing: Body changes
Action Urges : e.g., withdraw, attack, eat
Expressing: Behaviours – what you said or did
Aftereffects: Consequences – your state of mind; others’ reactions, reinforcements

39. Opposite Action
Fear
• Urge: Freeze, run, avoid
• Opposite action: Approach
Anger
• Urge: Attack, hit, yell
• Opposite action: Gently avoid; do something nice
Sadness
• Urge: Withdraw, cry, isolate
• Opposite action: Get active
Guilt/Shame
• Urge: Hide/avoid
• Opposite action: Face the music; repair mistakes
Changing ineffective emotions by ACTING OPPOSITE to the emotion

40. Skill modules : Interpersonal effectiveness
• Chaotic IPR is hallmark of BPD.
• Interpersonal stressor –common trigger for suicides.
• Teaches to identify factors interfering with interpersonal effectiveness, challenge
common cognitive distortion associated with interpersonal situation and determine
appropriate level of intensity for making responses or saying no in a situation.
• Taught what to say and how to say depending on priority and situation.
• Guidelines for being taken seriously , attending to relationship, and preserving self
respect .
• Instructed to practice new skills based on these guidelines .

41. Identifying Interpersonal
Priorities
Goal Effectiveness
• What do I want from the other person?
Relationship Effectiveness
• How do I want the other person to feel about me?
Self-Respect Effectiveness
• How do I want to feel about myself?

42. Goal Effectiveness
What to say:
Describe: Describe the situation. Stick to the facts.
Express: Express feelings using “I” statements.
Assert: Ask for what you want.
Reinforce: Explain positive effects of getting what you want.
How to say it:
Mindful: Keep your focus on what you want.
Appear confident: Make eye contact; confident tone of voice
Negotiate: Be willing to give to get. Ask for the other person’s input
Effectively making a request

43. Individual therapy
• DBT trained therapist
• Once a week
• 50 to 60 minutes
• To improve and maintain patient motivation.
• Validating environment is created in with patient is treated with compassion and
acceptance.
• Therapist and patient pursue behavior change.
• Skills learned are woven into skill plans in anticipation of upcoming events.

44. Individual therapy
• Episodes of emotional dysregulation from previous week are discussed –Skills
that could have been used .
• Factors interfering treatment progress-discussed
• Preventing problems -regarding new skill development.
• Help engage in treatment despite urge to drop out.

45. Diary cards
• To monitor variety of targets.
• Reviewed at the beginning of each session.
• Therapy sessions organized around targets evident on card.
• Is instrumental in directing therapy towards highly relevant targets.

47. Telephone consultation
• Therapist available 24 hour.
• Patients are encouraged to call when they feel themselves headed towards crisis that
might led to injurious behavior to self and others.
• Calls are indented to be brief and last about 10 minutes.
• The patient is not allowed to call the therapist for 24 hours after engaging in
parasuicidal behavior unless there are life-threatening injuries.
• The 24-hour rule is meant to encourage patients to seek help from the therapist at
earlier stages of a crisis while the therapist can still help and not after the patient has
already chosen maladaptive behaviors.

48. Consultation team
• All individual and group therapists who are currently providing DBT
• Therapists meet weekly to review their work with clients.
• By doing so they provide support for each other and maintain motivation in work.
• The meetings enable them to compare techniques used and to validate those
that are most effective

49. Consultation team agreement
1. Meet weekly for 1–2 hour
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
5. Do not expect consistency of therapists with one another (even across the same
patient)
6. Allow all therapists to observe their 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

51. References
• Linehan MM. . Cognitive-behavioral treatment of borderline personality disorder.
New York: Guilford Press; 1993.
• American Psychiatric Association. Diagnostic and statistical manual of mental
disorders. 5th ed. Washington: American Psychiatric Association; 2013.
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Philadelphia :Lippincott
Williams & Wilkins, 2000.
• Kaplan, H. I., Sadock, B. J., Boland, R., Verduin, M., & Ruiz, P. (2021). Kaplan &
Sadock's synopsis of psychiatry (12th ed.). Lippincott Williams & Wilkins (LWW).

52. Thank you