Dialectical behaviour therapy

About Dialectical Behaviour Therapy

Dialectical behaviour therapy

Dialectical behaviour therapy (DBT) is a psychological therapy for people with borderline personality disorder (BPD), especially those with self-harming behaviour or suicidal thoughts. 

If you have been diagnosed with BPD, you might have experienced the following:

• intense negative emotions (anger, shame, guilt, sadness, fear), which you find hard to control.
• impulsive behaviour to control your emotions, including self-harming, using alcohol or drugs, binge eating, purging etc.
• unstable relationships and fears of being abandoned by others
• feelings of emptiness
• mood swings, with your mood going up and down a lot
• suicide attempts
• self-harming.

DBT was specifically developed to address these problems.

Your present circumstances don't determine where you can go; they merely determine where you start.

(For more information about BPD, suicide and self-harm, see borderline personality disorder, how to cope with suicidal feelings and understanding self-harm.)

Why emotions are important in BPD

DBT suggests that if you have a diagnosis of BPD, your problems come mainly from difficulties in controlling your emotions.

You may have inherited genes that make you naturally more sensitive than others. Therefore, you may experience emotions more intensely than most people, and have more difficulty in letting go of intense emotions.

The environment you grew up in may also have played an important role; for example, you may have grown up with a family or school that did not help you learn how to experience and control your emotions. In such environments, you may have been expected to be ‘perfect’ and not to show any negative emotions; or your emotions may have been dismissed as incorrect, inappropriate or silly. For example, if you got upset because you lost a toy, your parents might have responded with “you can’t possibly be upset for just losing a toy!”, and to “stop over-reacting!”. You might also have experienced trauma (e.g. sexual or physical abuse, a loss) and have been told “not to be upset about it”.

Because in these environments a ‘normal’ display of emotions is not taken seriously or attended to, this may have resulted in you expressing your emotions more intensely to get a response, e.g. screaming and crying, instead of just saying that you are feeling sad. Because of this, you may not have learned when to trust your own feelings in a situation, how to recognise, accept and control intense emotions, or how to cope with distress.

As an adult, you might have adopted the features of the environment you grew up in – you feel that you shouldn’t be feeling the way you do, and that you should be able to deal with life’s problems. You might feel frustrated, ashamed and angry at yourself.

Before I started DBT, I believed that I did not really have a mental health problem; that I just needed to pull myself together, get a grip and stop wasting everyone’s time.

DBT suggests that in order to overcome these problems you need to learn how to control your emotions, and that the first step in doing so is to experience, recognise and accept your emotions. You can then start to reduce their intensity and let them go quicker.

In DBT, you are taught specific skills on how to do this.

Marsha Linehan developed DBT from cognitive behaviour therapy (CBT) and adapted it to meet the emotional needs of people diagnosed with BPD. CBT has traditionally focused on helping people change unhelpful ways of thinking and behaving. 

DBT also helps you to change, but it differs from CBT in that it focuses on accepting who you are at the same time. DBT therapists aim to balance ‘acceptance techniques’ with ‘change techniques’.

Acceptance techniques

Acceptance techniques focus on understanding and making sense of you as a person and the things you do. With these techniques, DBT therapists might point out that your behaviour (e.g. self-harming or using drugs) makes sense, even if it is not in your best interest in the long-term. It is often the only way you have learned to deal with intense emotions and has helped you to get through very difficult experiences. 

In DBT finally someone is saying 'yes, it makes sense' rather than 'no, that's wrong’.

Change techniques

DBT therapists use change techniques to encourage you to change your behaviour and learn more effective ways of dealing with your distress. They encourage you to replace behaviours that are harmful to you with behaviours that can help you move forward with your life.

Having a ‘pushy’ therapist in DBT kept me on track with making changes in my life.

The therapeutic relationship

If you have BPD, you may find that relationships are a key factor in keeping you alive and motivated. Therefore, DBT places particular importance on the relationship between you and your therapist, and this relationship is used to motivate you to change. 

I don't think I can say enough about how thankful I am to my therapist and the DBT team. I could never express how much their support meant to me and still means to me. My life changed in ways I never thought possible.

How is it different from other therapies?

How DBT is different from other therapies

A couple of alternatives that people might be offered as a treatment for BPD are psychodynamic psychotherapy or mentalisation-based therapy (MBT).

The main goal of psychodynamic psychotherapy is for you to gain a better understanding of yourself, often by linking your present experience with early childhood experiences. For example, you might realise that you feel insecure in relationships as an adult because your mother had neglected you when you were a child. It is suggested that this insight will then lead to solving your current problems.

Mentalisation-based therapy (MBT), is another form of psychodynamic psychotherapy that has been developed specifically to treat BPD and is also available on the NHS. It focuses on helping you understand how you think and behave in relationships. It is most often delivered in a group setting and works a lot with understanding relationships, as they develop in the group.

DBT differs in its treatment, in that it does not stop with understanding where problems come from or how you behave in relationships: changing your behaviour in the present is the main goal. It also focuses on changing harmful behaviours – particularly self-harming.

What form does it take?

What form does the treatment take?

Standard DBT has four elements

• a therapists’ consultation group
• individual therapy
• skills training in groups
• telephone crisis coaching with a therapist.

DBT programmes on the NHS usually offer treatment for a year, although this may vary across different services. It should also be noted that some DBT programmes may not necessarily offer all four elements of treatment.

Therapists’ consultation groups

DBT therapists usually work in teams, rather than independently, because working with people with suicidal ideas and self-harming behaviours can be stressful. Therapists therefore have a weekly session in which they discuss with each other issues that come up in your treatment. These sessions are used as a way for therapists to express their feelings and concerns about therapy or to ask for advice and different ideas that may help them to treat you more effectively. Thus you are actually treated by a team of therapists, rather than by just one therapist.

Individual therapy

Individual therapy involves one-to-one weekly psychotherapy sessions with a DBT therapist. The treatment was originally organised into four stages, with different goals for each stage. However, stage 1 is the most commonly offered stage (especially in NHS services), and the only one that has been evaluated in research. Therefore, we will only describe this stage here.

Treatment goals
The overall goal of stage 1 DBT is to help gain control over their behaviour. It has three main treatment goals:

• to keep you alive and safe – by stopping suicidal and self-harming behaviours
• to reduce behaviours that interfere with therapy – by addressing issues that might come in the way of you getting treatment, e.g. missing sessions, issues between you and your therapist
• to improve your quality of life – by addressing anything that interferes with this, e.g. other mental health problems, such as depression or hearing voices, traumatic experiences, employment or relationship problems.

The weekly sessions with your individual therapist will last 50–60 minutes. At the beginning of treatment, you and your therapist will set treatment goals, which include the DBT goals described above, as well as your personal goals and any changes that you want to make in your life. The sessions then focus on working on these agreed goals and solving problems that get in the way, such as self-harming, alcohol and substance misuse, or not attending sessions. 

You will be asked to complete diary cards in your everyday life to monitor your emotions and actions. You bring these cards to the sessions, where you and your therapist use this information to decide what you will work on that day. 

Solving specific behaviours
In DBT, you will not be encouraged to talk about your problems in general terms. Instead, you will focus on, and analyse in detail, specific problematic behaviours. 

For example, if you have self-harmed in the week before therapy, a specific incident of self-harming will be discussed and analysed, and you will look for solutions to the problem. This is called ‘behavioural and solution analysis’, and involves you and your therapist understanding:

• what led to that incident
• what might have made you more vulnerable
• what are the consequences of your behaviour.

Once you and your therapist have a clear picture of what led to the incident of self-harming, you work together to find realistic solutions that could prevent it from happening again. So, if alcohol makes you more vulnerable to self-harming, then not drinking could be a possible solution. 

Over time I began to see a pattern in situations that could provoke me to consider self-harm and I became able to make some changes.

Skills training in groups

These sessions are not group psychotherapy sessions; DBT therapists teach a group of people skills that can help them deal with life situations more effectively. Four main modules are taught:

• distress tolerance – teaching you how you can deal with crises in a more effective way, without having to resort to self-harming or other problematic behaviours
• interpersonal effectiveness – teaching you how to ask for things and say no to other people, while maintaining your self-respect and important relationships
• emotion regulation – a set of skills you can use to understand, be more aware and have more control over your emotions
• mindfulness – a set of skills that help you focus your attention and live your life in the present, rather than being distracted by worries about the past or the future.

There are usually two therapists in a group and the sessions last approximately two hours. You are given homework or tasks each week on the skills that have been covered during that particular skills training session. The purpose of the homework is to help you practise the skills in real-life situations. By completing the homework weekly, using the skills gradually becomes second nature and difficult situations can therefore be dealt with more effectively.

The repetition of the modules in the skills training sessions meant that even though I was fighting it and sometimes wanted to self-harm, I was constantly being reminded of alternative ways to deal with difficult situations.

Telephone crisis coaching

In DBT, crisis coaching is used to help you learn how to use your skills in real-life situations. You can telephone your individual therapist outside of therapy sessions in the following situations:

• when you need help to deal with a crisis situation (such as feeling suicidal, or the urge to self-harm)
• when you are trying to use DBT skills but want some advice on how to do it
• when you want to repair your relationship with your therapist.

Will I benefit?

Will I benefit from DBT?

Research shows that DBT leads to improvement in various problems related to BPD, such as self-harming, suicide attempts, depression, eating problems and feelings of hopelessness. The latest National Institute of Health and Clinical Excellence (NICE) guidelines propose DBT as the treatment of choice for women with BPD who want to reduce self-harming.

It is worth noting that most people find DBT difficult in the beginning, as it requires accepting your problems and working hard to change them. However, you might find out later that your efforts were worthwhile. 

Although for the first few years I found DBT skills almost impossible to use when I was very low and distressed, I now use DBT skills every day without even thinking about it. It can be life changing and I feel I can cope with my emotions so much better now than in the past, without resorting to self-harm.Although many people benefit from DBT, not everyone finds it helpful. Some people either discontinue their treatment or find it ineffective. 

You might find DBT too rigid, especially if you do not like doing homework.

If changing your self-harming behaviour is not your priority, you might also feel that the therapists do not accept you, or criticise you, since they focus so much on self-harming. 

If you are more interested in talking about your problems in general and understanding where they came from, DBT might not seem relevant to you.

Can I learn DBT techniques by myself?

When you start DBT you might feel overwhelmed by intense emotions, and find it hard or even impossible to attempt to solve your problems on your own. You may find that you understand the skills taught in DBT groups, but find them hard to apply in your daily life.

The structure of the DBT individual and group teaching sessions might be more appropriate than trying to learn the techniques by yourself. Discussions with therapists can help highlight potential situations where DBT skills can be practised, and your successes are acknowledged and congratulated in the group. Also, being with other people who experience similar problems for the skills training can be very supportive, as you realise that you are not alone – there are others who understand how you are feeling and go through the same difficulties. Individual therapy sessions can also help you to stay motivated if you have a difficult patch and feel like giving up.

It is relatively easy to find DBT ‘lessons’ online and to download diary cards, exercises and behavioural analysis sheets. The DBT Self Help website is a good source of information and resources. You might find that the self-help materials are suitable for refreshing the DBT training, but that they cannot take the place of attending therapy sessions.

Finding a therapist

How can I find a DBT therapist?

DBT is available on the NHS in some areas, and it is also available in the private sector, though there is no register of therapists at the time of writing. 

Your local GP or Community Mental Health Team should be able to provide information about local services. The British Isles DBT website and some other websites offer a list of both NHS and private services in the UK. It is unclear whether this is a comprehensive list of all UK DBT services and therapists.

You might want to bear in mind that private DBT therapists might not be able to deliver the whole standard DBT model. Similarly, they might be offering psychotherapy that includes DBT techniques, but that is not pure DBT.

Looking back, I feel that with DBT, an enormous burden has been taken off my shoulders and I was able to accept my past, and become more concerned with enjoying the moment and looking to the future. I also felt more confident and able to manage social situations without feeling ashamed or inadequate.

Useful contacts

Behavioral Tech
web: behavioraltech.org
The ‘official’ DBT website; offers information on BPD and DBT.

BPD World
web: bpdworld.org
Information on BPD and a directory of therapists (but it charges for this).

British Isles DBT
web: dbt.uk.net
List of DBT programmes in the UK (NHS and private).

Building a life worth living
web: buildingalifeworthliving.com
Service-user-led website with a list of NHS and private DBT therapists.

DBT Self Help
web: dbtselfhelp.com
Service-user-led website with information on DBT and relevant material, e.g. diary cards.

Emergence
web: emergenceplus.org.uk  
UK service-user-led website with information on BPD and a list of services for personality disorders.

Middle path
web: middle-path.org
Service-user-led website with information on BPD and DBT.

National Institute for Health and Clinical Excellence (NICE)
web: nice.org.uk
Guidelines for treatment within the National Health Service.

National Personality Disorder Website
web: personalitydisorder.org.uk
Information on personality disorders and their treatment.

RSCPP
web: rscpp.co.uk
Lists private counsellors/psychotherapists, including DBT therapists.

Published 2012
To be revised 2014
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