8 Psychotherapy8.2 Cognitive behavioural therapies
8.2.5 Dialectical behaviour therapy
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Written by Resident Doctor Committee · Published
Origins and indication
Dialectical behaviour therapy (DBT) was developed by Marsha Linehan for chronic suicidality and emotional dysregulation.
It joins cognitive behavioural change strategies with acceptance-based mindfulness taken from Zen meditative practice.
It is recommended in borderline personality disorder when reducing recurrent self-harm is the priority. NICE guidance names women with the disorder.
Its evidence for cutting self-harm is stronger than that for cognitive analytic therapy.
The biosocial model sees the disorder as emotional vulnerability interacting with an invalidating environment that dismisses or punishes the person's feelings.
Structure
A pre-treatment phase covers assessment, orientation, agreeing goals and securing commitment to the contract. No behaviour is targeted until stage 1.
Stage 1 targets follow a fixed hierarchy, with life-threatening behaviour at the top.
Priority | Target | Examples |
|---|---|---|
1 | Life-threatening behaviour | Suicidal acts, self-injury, suicidal communication |
2 | Therapy-interfering behaviour | Missed sessions, by therapist or patient |
3 | Quality-of-life-interfering behaviour | Substance use, housing crises |
4 | Skills acquisition | Learning the four modules |
Standard DBT works through behavioural, skills-based functions: building capability, generalising it, improving motivation, structuring the environment and supporting therapists. It does not work through insight, interpretation or catharsis.
The standard programme
Standard DBT combines weekly individual therapy, weekly group skills training, a therapist consultation team and telephone coaching.
Telephone coaching is scheduled, governed by the contract and built into the model, so that skills generalise to daily life between sessions.
Skills modules
Module | What it teaches |
|---|---|
Mindfulness | Observing and describing experience without judgement; the foundation for the others |
Emotion regulation | Identifying and labelling emotion, and reducing vulnerability to intense emotion |
Distress tolerance | Surviving a crisis when the situation cannot be changed |
Interpersonal effectiveness | Asking for what is needed and saying no while keeping relationships and self-respect |