Dialectical Behavior Therapy (DBT)

Dialectical Behavioral Therapy,  has established itself over the last twenty years as an elective treatment for borderline personality disorder (BPD). It was developed by Marsha Linehan at the University of Washington in Seattle (USA). Dialectical Behavioral Therapy is structured around the concept of “dialectical balance” between acceptance and change and identifies the psychopathological nucleus of borderline disorder in the following five points:

1. emotional dysregulation (e.g. affect lability, problems with anger management…);
2. interpersonal dysregulation (e.g. presence of chaotic relationships, fear of abandonment…);
3. dysregulation of the self (e.g. difficulty in maintaining a stable and coherent vision of one’s identity);
4. behavioral dysregulation (e.g. impulsive behavior, self-harm and suicidal behavior);
5. cognitive dysregulation (dissociative symptoms and transient paranoid states).

If you are facing borderline personality disorder or any other mental health problem then we provide dbt in London to help you overcome bpd.

Bio-psycho-social approach

According to Dialectical Behavioral Therapy, borderline personality disorder derives from the interaction between elements attributable to the patient’s individual biological vulnerability and some characteristics of his developmental environment. Individual biological vulnerability consists of three elements: (a) high sensitivity to stimuli (ie a low perceptual threshold for triggering emotional reactions); (b) high reactivity (ie tendency to immediacy in behavioral responses following an emotional arousal) and (c) slow return to the “baseline” of the activation (ie tendency to slowly restore a state of stillness). 

Principles of Dialectical Behavioral Therapy

Again according to the principles of Dialectical Behavioral Therapy, the component that makes biological vulnerability a risk factor for the development of a borderline personality disorder is the environmental invalidation: invalidating is any environment that considers an emotional reaction as “unjustified” or “not understandable” in the light of the situation, with a consequent tendency to simplify, trivialize and criticize. Trivialization and criticism, which often result in normative attitudes or advice regarding how it would be appropriate to feel and behave, presuppose that there is a univocal vision of the mental reality of the other person.

This attitude, in the long run, can weaken the individual’s ability to recognize internal experiences, to regulate emotions in an adaptive way, and to hold a view of internal experiences as “reliable guides” for behavior. Rather it will lead the person to “self-invalidate” (considering their emotions as “inadequate”, “dangerous”, “unmanageable”) and therefore to seek in the environment, rather than in itself, useful stimuli to direct one’s behavior and choices. Being exposed to environmental impairment involves a gradual and persistent deficit in the ability to express emotions effectively, in communicating one’s suffering to others and a tendency to oscillate between emotional inhibition and expression of emotions in a chaotic and extreme way.

In a nutshell:

In the person with biological vulnerability, systematic exposure to environmental impairment generates a shift from vulnerability to self-regulation deficit. Being exposed to environmental impairment involves a gradual and persistent deficit in the ability to express emotions effectively, in communicating one’s suffering to others and a tendency to oscillate between emotional inhibition and expression of emotions in a chaotic and extreme way. In a nutshell: in the person with biological vulnerability, systematic exposure to environmental impairment generates a shift from vulnerability to self-regulation deficit. Being exposed to environmental impairment involves a gradual and persistent deficit in the ability to express emotions effectively, in communicating one’s suffering to others and a tendency to oscillate between emotional inhibition and expression of emotions in a chaotic and extreme way. In a nutshell: in the person with biological vulnerability, systematic exposure to environmental impairment generates a shift from vulnerability to self-regulation deficit.

Treatment structure of Dialectical Behavioral Therapy

Treatment according to DBT is carried out by a therapeutic team and is divided into:

1. Individual psychotherapy;
2. Skills training group;
3. Telephone consultation;
4. Collateral interventions (e.g. family support, psychiatric care).

Individual psychotherapy in  Dialectical Behavioral Therapy

The aim of psychotherapeutic treatment is to improve the quality of life (or rather “to achieve a life worth living”) by identifying the problematic aspects of functioning but also the resources present. Of individual psychotherapy according to Dialectical Behavioral Therapy we can say that:

1. It has a behavioral approach, as it helps the person to identify and analyze problematic behaviors and the events that produce them, learning to replace them with adaptive behaviors.
2. It is a treatment of a cognitive nature as it helps the person to become aware of and change the dysfunctional beliefs and expectations learned during life that prove to be ineffective or penalizing (for example thinking for “all or nothing” or “black and white” ).
3. It teaches how to enhance the skills learned in the skills training group (see next paragraph) by helping to tolerate psychological suffering and to accept that “real changes” happen slowly.
4. It requires a collaborative relationship between therapist and patient, who progressively learn to work as a team focused on shared, explicit and common goals.

Furthermore, the psychotherapeutic intervention in Dialectical Behavioral Therapy proceeds with a precise order of priority: the first behaviors to be addressed are those that put the patient’s life and safety at risk (e.g. suicidal and para-suicidal behaviours), behaviors that can invalidate the usufruct of the therapy follow (e.g. occasional sessions, lack of engagement in home “homework”, inner ambivalences…) and finally those behaviors that interfere or decrease the patient’s quality of life (e.g. use of drugs, binges…).

Skills training groups in  Dialectical Behavioral Therapy

The skills training groups (which are not psychotherapy groups, but teaching groups) have a total duration of about six months and involve 4-8 participants. In them you learn fundamental skills briefly described below:

1. Interpersonal effectiveness: or the ability to implement effective behaviors to (a) achieve one’s goals, (b) maintain relationships and (c) maintain self-respect. Through this module the patient learns fundamental strategies to be effective in his relationship with others, learning to describe the problem he has, to express how this makes him feel, to affirm his own desire, to appear confident in the possibility of fulfilling it and open to negotiating how to do it.
2. Emotion regulation: i.e. the ability to (a) recognize one’s emotions and their functions, (b) recognize factors that increase vulnerability to negative emotions, and (c) reduce emotional distress. In this module the patient learns to reflect on the relationship between his internal states and the surrounding situation and to identify the behavioral impulses associated with the emotion he feels.
3. Tolerance of suffering : that is the ability to “survive” crisis situations without making them worse, accepting the presence of psychological pain and integrating it with the possibility of “going on”. Through this module the person learns to recognize the crisis and to apply specific coping strategies (for example: “stop” skills to promote self-control and continue to act consciously and management skills of intense emotions, acting on the “chemistry” of the body with relaxation and vigorous exercise).