How is the DPT program at UCSF

What is dialectical behavioral therapy / dialectical psychotherapy?

DBT: What characterizes the Dialectical Behavioral Therapy as a special form or method of psychotherapy? What advantages does the dialectical behavior therapy?

  • Dialectical Behavioral Behavior Therapy, in short DBT, is primarily used in patients with borderline personality disorders. Especially when they harm themselves or are suicidal. It was invented in the 1980s by Marsha Linehan. This therapy method is now also used for other diagnoses, for example eating disorders, addiction or PTSD. In fact, the diagnoses mentioned often occur together with borderline personality disorder.
  • Borderline patients are difficult to treat and break off therapy particularly often. This is because they react to the therapist in extreme ways. Either they keep too little distance or too much. Another problem is that these patients can easily feel rejected by the therapists. This can lead to violent reactions up to suicide attempt. Marsha Linehan analyzed the different behaviors of borderline patients and adapted the therapy methods accordingly. The dialectical behavior therapyAs the DBT is also called, it is a very practice-oriented therapy. (Linehan, 2008, foreword)
  • dialectic is a term from philosophy. It is about gaining new knowledge by bringing together contradicting theories in such a way that the contradiction is lifted. In the case of dialectical behavioral behavior therapy, this means accepting the patient for who they are on the one hand, and changing their behavior on the other. This works by accepting the patient's emotional experience, but at the same time learning techniques to better manage these feelings. (Kernbberg et al., 2001)

Dialectical Behavioral Therapy: Basic Ideas of DBT

  • Patients with borderline personality disorders cannot regulate their emotions enough. The emotions are experienced as extreme and uncontrollable. That also leads to social problems. Self-harm is a method of dealing with intense emotions and stress. (Kernberg et al., 2001) Dialectical behavioral psychotherapy starts with these problems and teaches those affected how to deal with them. In particular, they learn to regulate their emotions better and to be more mindful of themselves. The aim of treatment is for the patient to give up self-destructive behavior and appreciate himself. You also learn to better accept the circumstances. If these goals are achieved, the patient's quality of life improves. (Stiglmayr, 2017)
  • The basic attitude of the therapist is determined in this method. The therapist should assume that the patient cannot help his disorder and would like to change his behavior. This is necessary because borderline patients often do not give the impression that they are exerting themselves. (Stiglmayr, 2017)
  • Another basis of dialectical behavior therapy is that Zen Buddhism. This is expressed in different ways in the DBT. In this way, patients learn to be mindful of themselves and to be more tolerant of stress. This gives them a different attitude towards themselves and their environment and can deal with their feelings better. Accepting one's own painful experiences is also an element of Zen Buddhism and at the same time important for coping with trauma. (Huppertz, 2003)

DBT Therapy - Method and Methodology

  • Dialectical behavior therapy combines methods of cognitive therapy and behavior therapy. In addition, there are elements of gestalt therapy and hypnotherapy. Meditation techniques are also included (see also Meditation for Beginners). (Stieglmayr, 2017) In order to give the patient security, this therapy must be particularly clearly structured. The DBT starts with the patients themselves and is adapted to their needs and abilities. (Kernberg et al., 2001) The contradiction between strong structure and adaptability is probably another reason why this therapy is called dialectical.
  • Dialectical behavioral psychotherapy can last up to three years. It consists of a preparatory phase and three therapy phases. In the preparation phase, the patient's specific problems are analyzed. Therapy builds on this. If there are secondary diseases of the borderline disorder such as alcoholism or substance abuse, these should be treated first. The goals and agreements of the therapy are recorded in a therapy contract, which the patient and therapist sign. The contract is important so that the patient feels obliged and does not stop the therapy prematurely. (Stiglmayr, 2017)
  • The first phase of therapy works on the behaviors that cause the greatest problems. This phase of dialectical behavioral psychotherapy consists of individual sessions and group training. Acute problems and dangerous behavior are dealt with in individual settings. The behavior of the patient is listed and ranked according to danger. The most dangerous behavior is dealt with first. It always has priority, even if it comes back later in treatment. Social problems are also dealt with. A more stable social environment strengthens the patient and offers support. An important point in this phase of the DBT is also the behavior in the therapy itself. This should protect the therapist from burnout and ensure the continuation of the therapy. If there are other diseases that occur at the same time as the borderline disorder - for example eating disorders - these are treated in the first phase of therapy. Parallel to the individual sessions, various skills are trained in the group: social skills, stress tolerance and mindfulness. (Stiglmayr, 2017)
  • The second phase of therapy focuses on further reducing the stress on the patient. The self-damaging behavior should already be over by this time. As already started in phase one, the task is still to deal with social problems and illnesses. The skills learned in the group are deepened. (Stiglmayr, 2017)
  • The third phase of dialectical behavioral psychotherapy is ultimately about further practicing the skills. The patient's attitude towards himself plays the most important role. The subjects now are an increase in self-esteem and appreciation. Work is also carried out on the patient's personal goals. (Stiglmayr, 2017)
  • An important element of dialectical behavior therapy is the protocol. In the first phase of therapy, it is created weekly by the patient and discussed with the therapist at the beginning of each session. The patient documents the behavior with which he harms himself. The patient analyzes certain behaviors more precisely. Among other things, it is about: What exactly was done, how did the behavior come about, what were the consequences, what could have been done differently. This should make the patient aware of the consequences of their behavior and possible alternatives, thus ending the negative behavior in the long term. Therapy also includes telephone contact with the therapist. The therapist himself is supported by a team and supervision. (Stiglmayr, 2017)

Dialectical Behavior Therapy - Problems and Effectiveness

  • Problems arise from the strengths of dialectical behavioral therapy. One of them concerns Zen Buddhism. It is a very old philosophy that comes from a Far Eastern culture. Individualism does not play a role there, but it is very important for our western culture. The role of the therapist is authoritarian, despite all the required respect for the patient. (Huppertz, 2003) Gunia et al. (2000) see the problems in strict leadership, especially in group training. The patients want to share their experiences in the group, but this is not included in this concept. It's all about learning certain skills. This can be frustrating for both patients and therapists. Gunia et al. (2000) that there are many theories behind dialectical behavioral therapy. Precisely because it combines elements from different therapies and philosophies. This places high demands on the therapists, who have usually learned and practiced a certain form of therapy. The authors also suspect that patients also need a higher level of intelligence than for other therapies.
  • Ten studies on the effectiveness of dialectical behavioral therapy were combined for a meta-analysis. The result shows a strong effect. This means that DBT is an effective therapy method. However, ten studies are not that many. The authors of the meta-analysis admit that more studies are needed, especially in the inpatient area. (Kröger & Kosfelder, 2007)

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Dialectical Behavioral Therapy >> Sources and additional resources

  • (accessed on April 27, 2020)
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  • Gunia, H., Huppertz, M., Friedrich, J., & Ehrenthal, J. (2000). Dialectical behavioral therapy of borderline personality disorders in an outpatient network. Behavioral Therapy and Psychosocial Practice, 32 (4), 651-662.
  • Huppertz, M. (2003). The importance of Zen Buddhism for dialectical behavioral therapy. PPmP Psychotherapy Psychosomatics Medical Psychology, 53 (9/10), 376-383.
  • Kernberg, O. F., Clarkin, J. F., & Yeomans, F. E. (2001). Psychotherapy of the borderline personality. Manual for Transference Focused Psychotherapy (TFP). Stuttgart: Schattauer.
  • Kröger, C., & Kosfelder, J. (2007). A meta-analysis on the effectiveness of dialectical behavioral therapy in borderline personality disorders. Journal of Clinical Psychology and Psychotherapy, 36 (1), 11-17.
  • Linehan, M. (2008). Dialectical behavioral therapy for borderline personality disorder. Munich: Cip media.
  • Stiglmayr, C. (2017). Dialectical behavioral therapy for borderline personality disorder. PSYCH up2date, 11 (02), 151-164.