Dialectical behavior therapy (DBT) is developed for suicidal and destructive people with Borderline/Emotionally unstable personality disorder, IPS. The therapy aims to help the patient find a balance between his inner self and the external environment. It is also about learning to accept reality and yourself as you are and at the same time work for the necessary changes towards the goal of being able to live meaningfully.
During the 80s, Professor Marsha Linehan, at the University of Seattle, USA, found in her clinical work that conventional cognitive behavioral therapy did not work at all for suicidal and self-destructive women with Borderline, BPS, or Emotionally unstable personality disorder, IPS, as it is also called. Therefore, together with her colleagues, she developed Dialectical Behavior Therapy, DBT.
The development took place, among other things, based on a dialectical approach to life – polarity, togetherness and constant change. DBT has been shown to be able to help patients out of self-destructiveness, shorten treatment times, prevent hospitalization and prevent a chronic disease course.
At City Psychological Services we provide the service of DBT therapy in London. It is conducted both in inpatient and outpatient care, and is also used for other patient groups than self-harming and suicidal women with IPS. For example, for patients with the following problems:
• men with an IPS diagnosis
• morphine abuse
• severe eating disorder of a bulimic nature
• aggression and abuse problems
• young people with addiction and self-harming behaviors
• post-traumatic stress reaction
• old-age depression with suicidal elements.
What is DBT?
DBT can be described as a highly organized “aid” for patients in chaos and desperation. Caregivers are greatly affected and often feel helpless in trying to help these patients. The method is unique in that it protects the therapist’s motivation and “survival” as much as the patient’s.
DBT is considered a team treatment where each team member is responsible for all the team’s patients. The support of the team is crucial for the results of the treatments.
The central and overarching aspect of the therapy is to help the patient find a balance in his inner self and vis-à-vis the external environment. The patient is taught to accept reality and herself as she is and at the same time work for the necessary changes towards the goal of being able to live meaningfully.
The work is focused on identifying different dialectical life dilemmas and then creating a synthesis of the seemingly incompatible phenomena, for example being able to encompass conflicting desires of wanting to live and wanting to die, to love and loathe someone at the same time, to be both dependent and independent at the same time , strong and weak or having both bad and good sides.
DBT is also focused on teaching the patient to identify, cope with and manage emotional swings and impulses in order to minimize their self-harming behavior . There is also a strong focus on persuading the patient to remain in therapy even in the face of setbacks and on teaching her/him skills in managing conflict-ridden interpersonal relationships.
How does it happen?
The theoretical core of the treatment is learning theory and cognitive theory and the method is a cognitive behavioral therapy adapted for certain patient groups.
New elements are included in DBT in the form of training in conscious presence and acceptance . In this way, Eastern philosophy meets Western psychotherapy in this treatment model.
DBT, like most other modern psychotherapies, is principle-driven, but the work is done in a structured form that clearly defines what should be included in the treatment.
DBT is conducted in six channels:
• individual therapy
• group skills training
• the dialectical team
• extended telephone availability for crisis help.
• the patient as coordinator
• relative education
Skills training in a group – to provide life skills
In the skills training, which has a school character, you work your way through educational material divided into five sections:
1) conscious presence – to control your inner self,
2) to regulate emotions
3) to create and maintain good relationships,
4 ) to endure in crisis and
5) to confirm oneself and others – about validation.
The skills training is primarily psychopedagogical and not psychotherapeutic – you discuss, practice and role-play based on written material. Each episode takes about 8 weeks to work through.
Each patient must, it seems, commit to a rather demanding and active effort with different therapy elements every week and a large amount of homework. For this reason, a DBT treatment is not started until the patient has received full information about what awaits her/him and has been given the opportunity to actively choose this form of therapy.
Structure and phases in DBT
DBT begins with an orientation and contract phase that culminates in a contract to begin therapy if both parties and the team agree to this. The work in the therapy then follows different phases where each phase defines which goals should be prioritized:
- Prephase: Orientation, agreement, alliance and contract.
- Phase 1: Stability and security. The elimination or reduction of self-harm, suicidal thoughts, and actual suicide attempts. To increase skills in conscious presence, to regulate emotions, create and maintain good relationships and to endure a crisis.
- Phase 2: Looking back – Understanding yourself based on your history. To process and be able to live with trauma and grief. Being able to use new skills in many different everyday situations – so-called generalization
- Phase 3: Looking ahead and achieving personal goals – employment, housing, relationships, interests, dreams, visions, etc.
- Phase 4: Living in conscious presence, lasting will to live, motivation and involvement in one’s own life.