Explaining dialectical behaviour therapy (DBT)
Steve Roberts, Senior Therapist at the Priory Clinic Norwich provides an overview of Dialectical Behaviour Therapy (DBT), commonly used for the treatment of individuals with borderline personality disorder (BPD).
What is DBT?
DBT has become established as a widely researched and clinically effective long-term intervention. It has also been demonstrated as effective in treating patients with mood disorders, bipolar disorder, addiction and recovery from sexual abuse.
The DBT programme teaches patients the skills to decrease suicidal and self-injurious behaviour, manage emotions and improve their quality of life.
Who benefits from DBT?
Patients who benefit from DBT are often those who appear to be living chaotically and are perceived to be in a constant state of ‘crisis.’
Typically, such patients:
- Are highly susceptible to sudden and abnormal changes in emotions and have difficulty returning to a normal emotional state. For example, they might feel devastating grief where sadness would be expected, humiliation in place of disappointment and destructive rage instead of anger.
- Are likely to experience extreme feelings of rejection, failure, isolation and a sense of victimisation.
- Express impulsive behaviours frequently leading to the end of friendships and relationships and loss of employment. Individuals with BPD may enter a harmful cycle of the above behaviours leading to intense shame and guilt, which leads to further unhelpful attempts to soothe their emotional pain.
- Attempt to cope with emotional dysregulation in ways which are frequently harmful. Impulsive behaviours are common, including substance abuse or alcohol abuse, indiscriminate sexual behaviour, reckless spending, risk-taking, self-harm and para-suicidal behaviour.
Untreated BPD leads to escalation in the behaviours described above frequently resulting in serious self-harm, overdose and suicide. The rate of suicide in individuals with BPD is 8-10%, which is 400 times higher than the general population.
How does it work?
DBT comprises a mixture of group based skills training and individual therapy. Groups are always facilitated by two experienced therapists.
The skills have four elements:
- Mindfulness - the skill of observing one’s self and environment in the moment and non-judgmentally, is fundamental to DBT as it underpins all the other skills.
- Emotion regulation skills enable patients to moderate distressed emotional states and to understand moods and emotions more effectively.
- Distress tolerance skills enable patients to make sense of and manage crisis situations rather than ‘act out’ their emotions in old, destructive ways.
- Interpersonal effectiveness skills (a little like assertion skills) provide skills to help maintain positive relationships and limit interpersonal conflict which is often the cause of intense emotions.
The skills are introduced in the group, practiced during the week, recorded on diary cards and discussed in one-to-one therapy.
What makes DBT different?
The skills of DBT are drawn mainly from Cognitive Behavioural Therapy (CBT) but they are applied differently. In DBT, the focus is on the individual and how they can learn to understand and accept themselves.
There is a strong emphasis on developing a personal spiritual programme. It is not expected that patients simply learn the skills and make instant improvements. Instead, through personal commitment, the support of their peers in the group and the relentless encouragement of their therapist, patients come to see their DBT programme not just as therapy but as a way of life.
In DBT, the therapist is ‘active’ alongside the patients and, unlike most therapy, is more likely to disclose examples from their own life to support the therapeutic teaching and may be contacted by the patient on the phone between sessions.
In summary, DBT is not just a form of psychological therapy but a life-programme which patients use, initially to prevent serious self harm or suicide and ultimately to build fruitful, satisfying lives. DBT is a powerful programme which is often an unforgettable experience for patients and practitioners alike and one which undoubtedly has saved many lives.
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