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Mental Disorders

Dialectical Behavior Therapy for Personality Disorders (DBT)

Simone Hoermann, Ph.D., Corinne E. Zupanick, Psy.D. & Mark Dombeck, Ph.D.

Dialectical Behavior Therapy (DBT) can be considered a sub-type of traditional cognitive-behavioral therapy (CBT) as its origins can be traced to cognitive-behavioral theory.

DBT is an empirically supported treatment. It has been registered and reviewed by the Substance Abuse and Mental Health Services Administration (SAMHSA) as an evidence-based treatment. The theoretical underpinnings of DBT have previously been reviewed. Here we provide a brief summary:

angry older womanThe psychologist, Marsha Linehan initially developed DBT specifically to treat women with Borderline Personality Disorder. However, since its initial development, DBT's application has been successfully expanded to include other populations and other disorders. When Linehan first began working with therapy clients who were diagnosed with Borderline Personality Disorder, she initially followed a conventional cognitive-behavioral approach. However, she began to notice that people with Borderline Personality Disorder had a powerful, negative reaction to the heavy emphasis on change that is inherent in the cognitive-behavioral tradition of identifying and challenging beliefs, with the goal of altering negative behaviors.

Linehan recognized that people with Borderline Personality Disorder are exceptionally sensitive. They tend to have powerful emotional reactions to situations in which they feel invalidated. Their childhood histories often reflected a poor match between the emotional needs of such highly sensitive children, and their caregivers. This mismatch between caregiver and child created an environment in which the child's emotions were frequently invalidated. Invalidation occurs when caregivers punish, minimize, criticize, reject, or deny the validity of the child's emotional experience. This invalidation is evident in statements such as: "You're over-reacting" or, "For heaven's sake, grow up!" or, "Big boys don't cry."

Linehan concluded that the change emphasis of conventional CBT felt profoundly invalidating to her clients.  To these highly sensitive clients this emphasis on change caused them to feel as though something was wrong or unacceptable about them. This situation mirrored their painful childhood experiences of invalidation.  As a result, they could not engage in, nor benefit from therapy because the therapy itself was experienced as painfully invalidating.  In response to this insight, Linehan introduced several innovations to her therapeutic approach. The most important modification was a new emphasis on the acceptance and validation of the client's emotional and behavioral states. This acceptance counter-balanced the traditional CBT emphasis on changing those states. 

Clearly, people come to treatment because something is not working in their lives. They are asking for help to make some much needed changes.  This presented a therapeutic dilemma for Linehan because acceptance and change are incompatible agendas.  It is not possible for the therapist to suggest a better way to handle a situation without implicitly invalidating the way the client handled it in the first place.  Linehan's solution to this dilemma was to move back and forth between change and acceptance during therapy in a dialectical manner. The term dialectic means to find a resolution or compromise between things that seem contradictory or incompatible.   Some of the time she would be accepting and validating, while at other times she would be challenging and promoting change. She would switch back and forth according to her client's ability to tolerate the emotions that surrounded requests for change.