Should you use DBT in your practice?

You have probably heard the name Dialectical Behavior Therapy in your time as a therapist. It is one of the most ubiquitous therapeutic modalities out there, and with good reason: it’s also one of the most effective.



But as we have discussed before, grad programs barely cover therapeutic approaches beyond the basics. And getting officially certified in DBT can be a lengthy and expensive endeavor. How do you know if it’s something that would work with your caseload? Frankly, how do you even know what it is?



In this blog, we will cover the basics of DBT, including common applications, criticisms, and some modern offshoots and adaptations of the approach.



What is Dialectical Behavior Therapy?



Dialectical Behavior Therapy was created in the 1980s by Dr. Marsha Linehan, a therapist working with high suicidality and emotional dysregulation (Linehan & Wilks, 2015). Dr. Linehan and her colleagues were invested in adapting existing behavioral approaches, such as Cognitive Behavioral Therapy, to be effective in treating clients with severe or chronic mental illness (2015).



DBT is considered a best practice approach for working with clients with Borderline Personality Disorder, in which clients with a prior trauma history often present with severe mood lability as well as suicidal ideation (Linehan & Wilks, 2015). It is also used often with clients with BPD and a co-occurring substance use disorder, which may present similarly (Chapman, 2006). DBT is a skills-based approach focusing on developing mastery of four key competencies for managing painful emotions.



Standardized DBT treatment consists of multiple parts. First, clients attend regular group therapy sessions to learn the four core skills (Chapman, 2006). These groups are usually an hour or more in length, at a cadence of at least once weekly, but depending on the level of care you are in, it may be as often as daily. Second, clients attend individual therapy sessions with a DBT-trained therapist at least weekly. And third, therapists meet weekly for a consultation group with the other providers who are part of the client’s care team to coordinate together.



If this sounds intensive, it is intended to be that way – DBT is a highly structured modality that requires both clients and therapists to learn by repetition and practice.



Core concepts of DBT?



DBT treatment is divided into four modules, each focusing on developing mastery of a skill (Linehan & Wilks, 2015). They are:



1. Mindfulness
2. Interpersonal Effectiveness
3. Emotional Regulation
4. Distress Tolerance



While structured, DBT can also be adaptable to the needs of a client or to a specific presenting problem. Mindfulness is considered to be the primary, or “core” skill at the heart of a DBT approach, teaching clients to observe what is happening without judgment (Linehan & Wilks, 2015).



Though mindfulness is typically taught first, some clients might benefit from starting with distress tolerance, to increase their ability to manage discomfort. In other cases, clients might need to develop emotional regulation at the start of treatment, allowing them to respond differently to unwanted or unpleasant emotions (Linehan & Wilks, 2015). In DBT, there is some flexibility to allow for clinical judgment.^



Criticisms of DBT



A chief complaint of many clinicians and clients is that DBT requires significant investment of time, energy, and resources. The original DBT model asks clients to attend multiple therapy sessions per week, which may be lengthy or emotionally heavy. There may also be homework to encourage skills practice outside of sessions. Social determinants of health may create an additional barrier, as not everyone can afford the time off work or out-of-pocket costs to attend a DBT program.



The introduction of the DBT manual, a workbook used as a guide in treatment settings, states, “the hard part will be making the commitment to do the[se] exercises and to put your new skills into practice. Nothing will change by just reading this workbook” (McKay, Wood, & Brantley, 2019, p. 2). The authors know this is a big ask, and they are making it anyway. Nothing changes if nothing changes, as they say.



A secondary criticism of DBT is that the rigid focus on skill-building lacks room for formal, built-in trauma processing. For many DBT participants, a trauma history is a given. Borderline Personality Disorder and substance use disorders are both considered traumagenic, meaning that they result from the impact of past traumatic experiences on the brain and nervous system. Given that DBT is considered a best practice for working with trauma-related conditions, skills alone may not be enough to promote recovery.



Modern Applications of DBT



So how do therapists modify DBT to address these flaws? By thinking creatively.



In my practice, I often combine DBT skills with other therapeutic modalities. For example, when I see clients struggling with OCD, we first focus on developing a robust toolbox of distress tolerance skills before starting exposure therapy. Mindfulness, too, has a number of applicable uses in therapy, and can be used to help clients develop the mind/body connection. This is highly important in sex therapy work, as well as in perinatal mental health, two settings where clients might feel disconnected or uncomfortable in their bodies and minds.



More formal adaptations of DBT have emerged over the years as well. Radically Open DBT was developed for work with clients who struggle with inflexibility and emotional expression, such as in eating disorder treatment (Hempel, Vanderbleek & Lynch, 2018).



Other spinoffs of the traditional DBT model include DBT for adolescents, for substance abuse, and prolonged exposure. DBT-PE focuses specifically on the critique that DBT does not allow for trauma processing, building in treatment time for desensitization to the trauma trigger (DBT PE, 2018).

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Final Thoughts



Using DBT as a therapist can seem daunting at first. There is a lot to learn, and to stay true to the model, a lot to teach as well. But just like learning the DBT skills themselves, with time and practice, you can start to make this approach your own.