Editing Dialectical behavior therapy

{{Short description|Psychotherapy for emotional dysregulation}}
{{Use American English|date=December 2022}}
{{Use mdy dates|date=December 2022}}
[[File:Dialectical Behavior Therapy Cycle EN.jpg|thumb|The skills modules in dialectical behavior therapy]]
{{Mindfulness|Psychology}}

'''Dialectical behavior therapy''' ('''DBT''') is an evidence-based<ref name="ReferenceA">{{Cite journal |last=Chapman |first=AL |year=2006 |title=Dialectical behavior therapy: current indications and unique elements |journal=Psychiatry (Edgmont) |volume=3 |issue=9 |pages=62–8 |pmc=2963469 |pmid=20975829}}</ref> [[psychotherapy]] that began with efforts to treat [[personality disorder]]s and interpersonal conflicts.<ref name="ReferenceA" /> Evidence suggests that DBT can be useful in treating [[mood disorder]]s and [[suicidal ideation]] as well as for changing behavioral patterns such as [[self-harm]] and [[Substance use disorder|substance use]].<ref>{{Cite web |date=May 17, 2016 |title=An Overview of Dialectical Behavior Therapy – Psych Central |url=http://psychcentral.com/lib/an-overview-of-dialectical-behavior-therapy/0001096 |access-date=January 19, 2015}}</ref> DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical [[dialectic]]al process of thesis and antithesis, followed by synthesis.<ref name="ReferenceA" />

This approach was developed by [[Marsha M. Linehan]], a psychology researcher at the [[University of Washington]]. She defines it as "a synthesis or integration of opposites".<ref name="nutshell"/> DBT was designed to help people increase their emotional and cognitive regulation by learning about the triggers that lead to reactive states and by helping to assess which coping skills to apply in the sequence of events, thoughts, feelings, and behaviors to help avoid undesired reactions. Linehan later disclosed to the public her own struggles and belief that she suffers from [[borderline personality disorder]].<ref>{{cite web |last1=Carey |first1=Benedict |title=Expert on Mental Illness Reveals Her Own Struggle - The New York Times |url=https://www.nytimes.com/2011/06/23/health/23lives.html |website=[[nytimes.com]] |access-date=22 December 2024}}</ref>

DBT grew out of a series of failed attempts to apply the standard [[cognitive behavioral therapy]] (CBT) protocols of the late 1970s to chronically suicidal clients.<ref name="nutshell" /> Research on its effectiveness in treating other conditions has been fruitful.<ref name=":02">{{Cite web |last=Linehan |first=Marsha M. |year=2014 |title={{title case| Research on Dialectical Behavior Therapy: Summary of Non-RCT Studies}} |url=http://behavioraltech.org/downloads/Research-on-DBT_Summary-of-Data-to-Date.pdf |access-date=December 11, 2016 |website=guilford.com |publisher=Guilford Press |edition=2nd |archive-date=October 10, 2017 |archive-url=https://web.archive.org/web/20171010004504/http://behavioraltech.org/downloads/Research-on-DBT_Summary-of-Data-to-Date.pdf |url-status=dead }}</ref> DBT has been used by practitioners to treat people with [[Major depressive disorder|depression]], drug and alcohol problems,<ref>{{Cite journal |last1=Dimeff |first1=LA |last2=Linehan |first2=MM |year=2008 |title=Dialectical behavior therapy for substance abusers |journal=Addict Sci Clin Pract |volume=4 |issue=2 |pages=39–47 |doi=10.1151/ascp084239 |doi-broken-date=December 5, 2024 |pmc=2797106 |pmid=18497717}}</ref> [[post-traumatic stress disorder]] (PTSD),<ref name="behavioraltech.org">{{Cite web |title=What is Dialectical Behavior Therapy (DBT)? |url=https://behavioraltech.org/resources/faqs/dialectical-behavior-therapy-dbt/ |access-date=November 30, 2017 |website=Behavioral Tech}}</ref> [[traumatic brain injuries]] (TBI), binge-eating disorder,<ref name="ReferenceA" /> and mood disorders.<ref name="isbn0-88048-761-5">{{Cite book |last=Janowsky |first=David S. |url=https://archive.org/details/psychotherapyind0000unse/page/100 |title=Psychotherapy indications and outcomes |publisher=American Psychiatric Press |year=1999 |isbn=978-0-88048-761-0 |location=Washington, DC |pages=[https://archive.org/details/psychotherapyind0000unse/page/100 100]}}</ref><ref name="nutshell">{{Cite journal |last1=Linehan |first1=M. M. |last2=Dimeff |first2=L. |year=2001 |title=Dialectical Behavior Therapy in a nutshell |url=https://www.ebrightcollaborative.com/uploads/2/3/3/9/23399186/dbtinanutshell.pdf |journal=The California Psychologist |volume=34 |pages=10–13}}</ref> Research indicates that DBT might help patients with symptoms and behaviors associated with [[Affective spectrum|spectrum mood disorders]], including self-injury.<ref>{{Cite news |last=Brody |first=Jane E. |date=May 6, 2008 |title=The Growing Wave of Teenage Self-Injury |work=The New York Times |url=https://www.nytimes.com/2008/05/06/health/06brod.html |access-date=December 24, 2022 |issn=0362-4331}}</ref> Work also suggests its effectiveness with sexual-abuse survivors<ref>{{Cite journal |last1=Decker |first1=S.E. |last2=Naugle |first2=A.E. |year=2008 |title=DBT for Sexual Abuse Survivors: Current Status and Future Directions |url=http://www.baojournal.com/JOBA-OVTP/JOBA-OVTP-VOL-1/JOBA-OVTP-1-4.pdf |url-status=dead |journal=Journal of Behavior Analysis of Offender and Victim: Treatment and Prevention |volume=1 |issue=4 |pages=52–69 |doi=10.1037/h0100456 |archive-url=https://web.archive.org/web/20101229151823/http://www.baojournal.com/JOBA-OVTP/JOBA-OVTP-VOL-1/JOBA-OVTP-1-4.pdf |archive-date=December 29, 2010}}</ref> and chemical dependency.<ref>{{Cite journal |last1=Linehan |first1=Marsha M. |last2=Schmidt |first2=Henry III |last3=Dimeff |first3=Linda A. |last4=Craft |first4=J. Christopher |last5=Kanter |first5=Jonathan |last6=Comtois |first6=Katherine A. |year=1999 |title=Dialectical Behavior Therapy for Patients with Borderline Personality Disorder and Drug-Dependence |journal=American Journal on Addictions |volume=8 |issue=4 |pages=279–292 |doi=10.1080/105504999305686 |pmid=10598211}}</ref>

DBT combines standard cognitive-behavioral techniques for [[Emotional self-regulation|emotion regulation]] and [[Reality testing|reality-testing]] with concepts of [[distress tolerance]], acceptance, and [[Mindfulness|mindful awareness]] largely derived from contemplative meditative practice. DBT is based upon the [[biosocial theory]] of mental illness and is the first therapy that has been experimentally demonstrated to be generally effective in treating borderline personality disorder (BPD).<ref>{{Cite journal |last1=Linehan |first1=M. M. |last2=Armstrong |first2=H. E. |last3=Suarez |first3=A. |last4=Allmon |first4=D. |last5=Heard |first5=H. L. |year=1991 |title=Cognitive-behavioral treatment of chronically parasuicidal borderline patients |journal=Archives of General Psychiatry |volume=48 |issue=12 |pages=1060–64 |doi=10.1001/archpsyc.1991.01810360024003 |pmid=1845222}}</ref><ref>{{Cite journal |last1=Linehan |first1=M. M. |last2=Heard |first2=H. L. |last3=Armstrong |first3=H. E. |year=1993 |title=Naturalistic follow-up of a behavioural treatment of chronically parasuicidal borderline patients |journal=Archives of General Psychiatry |volume=50 |issue=12 |pages=971–974 |doi=10.1001/archpsyc.1993.01820240055007 |pmid=8250683}}</ref> The first randomized clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalizations, and treatment dropouts when compared to usual treatment.<ref name="nutshell" /> A meta-analysis found that DBT reached moderate effects in individuals with BPD.<ref>{{Cite journal |last1=Kliem |first1=S. |last2=Kröger |first2=C. |last3=Kossfelder |first3=J. |name-list-style=amp |year=2010 |title=Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling |journal=Journal of Consulting and Clinical Psychology |volume=78 |issue=6 |pages=936–951 |citeseerx=10.1.1.456.8102 |doi=10.1037/a0021015 |pmid=21114345}}</ref> DBT may not be appropriate as a universal intervention, as it was shown to be harmful or have null effects in a study of an adapted DBT skills-training intervention in adolescents in schools, though conclusions of [[Iatrogenesis|iatrogenic]] harm are unwarranted as the majority of participants did not significantly engage with the assigned activities with higher engagement predicting more positive outcomes.<ref>{{Cite journal |last1=Harvey |first1=Lauren J. |last2=White |first2=Fiona A. |last3=Hunt |first3=Caroline |last4=Abbott |first4=Maree |date=2023-10-01 |title=Investigating the efficacy of a Dialectical behaviour therapy-based universal intervention on adolescent social and emotional well-being outcomes |journal=Behaviour Research and Therapy |volume=169 |pages=104408 |doi=10.1016/j.brat.2023.104408 |pmid=37804543 |issn=0005-7967|doi-access=free }}</ref>

==Overview==
DBT is sometimes considered a part of the [[Cognitive behavioral therapy#Merger of behavioral and cognitive therapies|"third wave" of cognitive-behavioral therapy]], as DBT adapts CBT to assist patients in dealing with stress.<ref>{{Cite journal |last1=Bass |first1=Christopher |last2=van Nevel |first2=Jolene |last3=Swart |first3=Joan |year=2014 |title=A comparison between dialectical behavior therapy, mode deactivation therapy, cognitive behavioral therapy, and acceptance and commitment therapy in the treatment of adolescents. |journal=International Journal of Behavioral Consultation and Therapy |volume=9 |issue=2 |pages=4–8 |doi=10.1037/h0100991}}</ref><ref>{{Cite journal |last1=Hofmann |first1=Stefan G. |last2=Sawyer |first2=Alice T. |last3=Fang |first3=Angela |date=September 1, 2010 |title=The Empirical Status of the 'New Wave' of Cognitive Behavioral Therapy |journal=Psychiatric Clinics of North America |language=en |volume=33 |issue=3 |pages=701–710 |doi=10.1016/j.psc.2010.04.006 |issn=0193-953X |pmc=2898899 |pmid=20599141}}</ref> DBT focuses on treating disorders that are characterised by impulsivity and emotional dysregulation.<ref>{{cite journal |last1=Gilbert |first1=Kirsten |last2=Hall |first2=Karyn |last3=Codd |first3=R Trent |title=Radically Open Dialectical Behavior Therapy: Social Signaling, Transdiagnostic Utility and Current Evidence |journal=[[Psychology Research and Behavior Management]] |date=8 January 2020 |volume=13 |pages=19–28 |doi=10.2147/PRBM.S201848 |pmid=32021506 |pmc=6955577 |issn=1179-1578 |doi-access=free }}</ref>

DBT strives to have the patient view the therapist as an accepting [[alliance|ally]] rather than an [[enemy|adversary]] in the treatment of psychological issues: many treatments at this time left patients feeling "criticized, misunderstood, and invalidated" due to the way these methods "focused on changing cognitions and behaviors."<ref name="ReferenceA"/> Accordingly, the therapist aims to accept and [[wikt:validate|validate]] the client's feelings at any given time, while, nonetheless, informing the client that some feelings and behaviors are [[maladaptive]], and showing them better alternatives.<ref name="nutshell" /> In particular, DBT targets self-harm and [[suicide attempt]]s by identifying the function of that behavior and obtaining that function safely through DBT coping skills.<ref>{{cite journal |last1=Clarke |first1=Stephanie |last2=Allerhand |first2=Lauren A. |last3=Berk |first3=Michele S. |title=Recent advances in understanding and managing self-harm in adolescents |journal=[[F1000Research]] |date=24 October 2019 |volume=8 |pages=1794 |doi=10.12688/f1000research.19868.1|pmid=31681470 |pmc=6816451 |doi-access=free }}</ref> DBT focuses on the client acquiring new skills and changing their behaviors,<ref>{{Cite journal |last1=Choi-Kain |first1=Lois W. |last2=Finch |first2=Ellen F. |last3=Masland |first3=Sara R. |last4=Jenkins |first4=James A. |last5=Unruh |first5=Brandon T. |date=February 3, 2017 |title=What Works in the Treatment of Borderline Personality Disorder |journal=Current Behavioral Neuroscience Reports |volume=4 |issue=1 |pages=21–30 |doi=10.1007/s40473-017-0103-z |pmc=5340835 |pmid=28331780}}</ref> with the ultimate goal of achieving a "life worth living".<ref name="ReferenceA"/>

In DBT's biosocial theory of BPD, clients have a biological predisposition for [[emotional dysregulation]], and their social environment validates maladaptive behavior.<ref>{{Cite journal |last1=Little |first1=Hannah |last2=Tickle |first2=Anna |last3=das Nair |first3=Roshan |date=October 16, 2017 |title=Process and impact of dialectical behaviour therapy: A systematic review of perceptions of clients with a diagnosis of borderline personality disorder |journal=Psychology and Psychotherapy: Theory, Research and Practice |volume=91 |issue=3 |pages=278–301 |doi=10.1111/papt.12156 |pmid=29034599 |s2cid=32268378|url=https://nottingham-repository.worktribe.com/file/888123/1/PPTRP.16.0155_R1%20Manuscript%20resubmission.pdf }}</ref>

DBT skills training alone is being used to address treatment goals in some clinical settings,<ref>{{Cite journal |last1=Valentine |first1=Sarah E. |last2=Bankoff |first2=Sarah M. |last3=Poulin |first3=Renée M. |last4=Reidler |first4=Esther B. |last5=Pantalone |first5=David W. |date=January 2015 |title=The Use of Dialectical Behavior Therapy Skills Training as Stand-Alone Treatment: A Systematic Review of the Treatment Outcome Literature |journal=[[Journal of Clinical Psychology]] |volume=71 |issue=1 |pages=1–20 |doi=10.1002/jclp.22114 |pmid=25042066}}</ref> and the broader goal of [[emotion regulation]] that is seen in DBT has allowed it to be used in new settings, for example, supporting [[parenting]].<ref>{{Cite journal |last1=Zalewski |first1=Maureen |last2=Lewis |first2=Jennifer K |last3=Martin |first3=Christina Gamache |date=June 2018 |title=Identifying novel applications of dialectical behavior therapy: considering emotion regulation and parenting |journal=[[Current Opinion in Psychology]] |volume=21 |pages=122–126 |doi=10.1016/j.copsyc.2018.02.013 |pmid=29529427 |s2cid=3838955}}</ref> There has been little study into adapting DBT into an online environment, but a review indicates that attendance is improved online, with comparable improvements for clients to the traditional mode.<ref>{{cite journal |last1=Lakeman |first1=Richard |last2=King |first2=Peter |last3=Hurley |first3=John |last4=Tranter |first4=Richard |last5=Leggett |first5=Andrew |last6=Campbell |first6=Katrina |last7=Herrera |first7=Claudia |title=Towards online delivery of Dialectical Behaviour Therapy: A scoping review |journal=[[International Journal of Mental Health Nursing]] |date=August 2022 |volume=31 |issue=4 |pages=843–856 |doi=10.1111/inm.12976|pmid=35048482 |pmc=9305106 }}</ref>

==Four modules==
=== Mindfulness ===
[[File:DBT Wise mind.png|thumb|DBT wise mind—the synthesis of the two opposites: reasonable mind and emotion mind]]{{further|Mindfulness}}

Mindfulness is one of the core ideas behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations.

The concept of mindfulness and the meditative exercises used to teach it are derived from traditional contemplative religious practice, though the version taught in DBT does not involve any religious or [[Metaphysics|metaphysical]] concepts. Within DBT it is the capacity to pay attention, nonjudgmentally, to the present moment; about living in the moment, experiencing one's emotions and senses fully, yet with perspective. The practice of mindfulness can also be intended to make people more aware of their environments through their five senses: touch, smell, sight, taste, and sound.<ref>{{Cite web |title=What is Mindfulness? – The Linehan Institute |url=http://www.linehaninstitute.org/mindfulness/ |access-date=September 21, 2017 |website=linehaninstitute.org |language=en-US}}</ref> Mindfulness relies heavily on the principle of acceptance, sometimes referred to as "radical acceptance". Acceptance skills rely on the patient's ability to view situations with no judgment, and to accept situations and their accompanying emotions. This causes less distress overall, which can result in reduced discomfort and symptomology.

==== Acceptance and change ====
The first few sessions of DBT introduce the dialectic of acceptance and change. The patient must first become comfortable with the idea of therapy; once the patient and therapist have established a trusting relationship, DBT techniques can flourish. An essential part of learning acceptance is to first grasp the idea of radical acceptance: radical acceptance embraces the idea of facing situations, both positive and negative, without judgment. Acceptance also incorporates mindfulness and emotional regulation skills, which depend on the idea of radical acceptance. These skills, specifically, are what set DBT apart from other therapies.

Often, after a patient becomes familiar with the idea of acceptance, they will accompany it with change. DBT has five specific states of change which the therapist will review with the patient: pre-contemplation, contemplation, preparation, action, and maintenance.<ref name=":12">{{Cite book |last=Ellen |first=Astrachan-Fletcher |title=The dialectical behavior therapy skills workbook for bulimia using DBT to break the cycle and regain control of your life |date=2009 |publisher=New Harbinger Publications |isbn=9781608822560 |oclc=955646721}}</ref> Precontemplation is the first stage, in which the patient is completely unaware of their problem. In the second stage, contemplation, the patient realizes the reality of their illness: this is not an action, but a realization. It is not until the third stage, preparation, that the patient is likely to take action, and prepares to move forward. This could be as simple as researching or contacting therapists. Finally, in stage 4, the patient takes action and receives treatment. In the final stage, maintenance, the patient must strengthen their change in order to prevent relapse. After grasping acceptance and change, a patient can fully advance to mindfulness techniques.

There are six mindfulness skills used in DBT to bring the client closer to achieving a "wise mind", the synthesis of the rational mind and emotional mind: three "what" skills (observe, describe, participate) and three "how" skills (nonjudgementally, one-mindfully, effectively).<ref name="Pederson2015ch19">{{Cite book |last=Pederson |first=Lane |title=Dialectical behavior therapy: a contemporary guide for practitioners |date=2015 |publisher=Wiley |isbn=9781118957882 |location=Chichester, West Sussex |chapter=19 Skills Training}}</ref>

===Distress tolerance===
{{further|Distress tolerance}}
The concept of distress tolerance arose from methods used in person-centered, [[psychodynamic therapy|psychodynamic]], [[psychoanalytic therapy|psychoanalytic]], [[gestalt therapy|gestalt]], and/or [[narrative therapy|narrative]] therapies, along with religious and spiritual practices.  Distress tolerance means learning to bear emotional discomfort skillfully, without resorting to maladaptive reactions. Healthier coping behaviors are learned, including intentional self-distraction, self-soothing, and 'radical acceptance.'<ref name=Pederson2015ch19/>

Distress tolerance skills are meant to arise naturally as a consequence of mindfulness. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. It is meant to be a non-judgmental stance, one of neither approval nor resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into intense, desperate, and often destructive emotional reactions.<ref name="DBTSkills">{{Cite web |last=Dietz |first=Lisa |year=2003 |title=DBT Skills List |url=http://www.dbtselfhelp.com/html/dbt_skills_list.html |access-date=April 26, 2010 |archive-date=January 14, 2013 |archive-url=https://web.archive.org/web/20130114010357/http://www.dbtselfhelp.com/html/dbt_skills_list.html |url-status=dead }}</ref>

===Emotion regulation===
{{further|Emotional self-regulation}}
Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and [[labile mood|labile]]. They can be angry, intensely frustrated, depressed, or anxious. The theory holds that intense emotions are conditioned responses to distressing experiences, which serve as the conditioned stimuli. Emotional regulation skills are taught to help patients modify their conditioned responses.<ref name=manual2014>{{Cite book|url=https://www.guilford.com/books/DBT-Skills-Training-Manual/Marsha-Linehan/9781462516995|title=DBT Skills Training Manual |edition=2nd |last=Linehan|first=Marsha M. |date=2014|publisher=Guilford Press|access-date=11 December 2016}}</ref>

Dialectical behavior therapy skills for emotion regulation include:

* Learning how to understand and name emotions: the patient focuses on recognizing their feelings. This segment relates directly to mindfulness, which also exposes a patient to their emotions.
* Identify obstacles to changing emotions
* Changing unwanted emotions: the therapist emphasizes the use of opposite-reactions, fact-checking, and problem solving to regulate emotions. While using opposite-reactions, the patient targets distressing feelings by responding with the opposite emotion.
* Reducing vulnerability: the patient learns to accumulate positive emotions and to plan coping mechanisms in advance, in order to better handle difficult experiences in the future. 
* Increase mindfulness to current emotions
* Take opposite action
* Apply distress tolerance techniques
* Managing extreme conditions: the patient focuses on incorporating their use of mindfulness skills to their current emotions, to remain stable and alert in a crisis.<ref name=manual2014/><ref name=DBTSkills/><ref>{{Cite journal |last1=Holmes |first1=P. |last2=Georgescu |first2=S. |last3=Liles |first3=W. |name-list-style=amp |year=2005 |title=Further delineating the applicability of acceptance and change to private responses: The example of dialectical behavior therapy |url=http://psycnet.apa.org/journals/bar/7/3/311.pdf |journal=The Behavior Analyst Today |volume=7 |issue=3 |pages=301–311}}</ref>

===Interpersonal effectiveness===
The three interpersonal skills focused on in DBT include [[self-respect]], treating others "with care, interest, validation, and respect", and [[assertiveness]].  The dialectic involved in healthy relationships involves balancing the needs of others with the needs of the self, while maintaining one's self-respect.<ref>{{Cite book |last=Pederson |first=Lane |title=The expanded dialectical behavior therapy skills training manual: practical DBT for self-help, and individual and group treatment settings |date=2012 |publisher=Premier Pub. & Media |isbn=9781936128129 |location=Eau Claire, WI |chapter=Interpersonal Effectiveness}}</ref>

==Tools==

=== Diary cards ===
Specially formatted diary cards can be used to track relevant emotions and behaviors. Diary cards are most useful when they are filled out daily.<ref>{{Cite web |title=Dialectical Behavior Therapy Applications for People with Borderline Personality Disorder |url=https://community.counseling.org/blogs/david-metzner1/2021/04/10/DBT-applications-for-BPD |access-date=June 7, 2021 |website=community.counseling.org |language=en}}</ref> The diary card is used to find the treatment priorities that guide the agenda of each therapy session.  Both the client and therapist can use the diary card to see what has improved, gotten worse, or stayed the same.<ref>{{Cite book |last=Pederson |first=Lane |title=Dialectical behavior therapy: a contemporary guide for practitioners |date=2015 |publisher=Wiley |isbn=9781118957882 |location=Chichester, West Sussex |chapter=13 Self-Monitoring with the Diary Card}}</ref>

===Chain analysis===
[[File:Chain analysis of problem behaviour.png|thumb|right|Chain analysis— from a prompting event to the problem behavior and consequences]]

Chain analysis is a form of [[functional analysis (psychology)|functional analysis]] of behavior but with increased focus on sequential events that form the behavior chain. It has strong roots in behavioral psychology in particular [[applied behavior analysis]] concept of chaining.<ref>{{Cite journal |last1=Sampl |first1=S. |last2=Wakai |first2=S. |last3=Trestman |first3=R. |last4=Keeney |first4=E.M. |name-list-style=amp |year=2008 |title=Functional Analysis of Behavior in Corrections: Empowering Inmates in Skills Training Groups |journal=Journal of Behavior Analysis of Offender and Victim: Treatment and Prevention |volume=1 |issue=4 |pages=42–51 |doi=10.1037/h0100455}}</ref> A growing body of research supports the use of behavior chain analysis with multiple populations.<ref>{{Cite web |title=Self Awareness and Insight Through Dialectical Behavior Therapy: The Chain Analysis |url=http://www.parkslopetherapy.net/2015/05/self-awareness-and-insight-through.html |website=parkslopetherapy.net |access-date=July 28, 2017 |archive-date=July 28, 2017 |archive-url=https://web.archive.org/web/20170728222800/http://www.parkslopetherapy.net/2015/05/self-awareness-and-insight-through.html |url-status=dead }}</ref>

==Efficacy==

===Borderline personality disorder===
DBT is the therapy that has been studied the most for treatment of borderline personality disorder, and there have been enough studies done to conclude that DBT is helpful in treating borderline personality disorder.<ref>{{Cite journal |last1=Stoffers |first1=JM |last2=Völlm |first2=BA |last3=Rücker |first3=G |last4=Timmer |first4=A |last5=Huband |first5=N |last6=Lieb |first6=K |date=August 15, 2012 |title=Psychological therapies for people with borderline personality disorder |journal=The Cochrane Database of Systematic Reviews |volume=8 |issue=8 |pages=CD005652 |doi=10.1002/14651858.CD005652.pub2 |pmc=6481907 |pmid=22895952}}</ref> Several studies have found there are neurobiological changes in individuals with BPD after DBT treatment.<ref>{{cite journal |last1=Iskric |first1=Adam |last2=Barkley-Levenson |first2=Emily |title=Neural Changes in Borderline Personality Disorder After Dialectical Behavior Therapy–A Review |journal=[[Frontiers in Psychiatry]] |date=17 December 2021 |volume=12 |pages=772081 |doi=10.3389/fpsyt.2021.772081|pmid=34975574 |pmc=8718753 |doi-access=free }}</ref>

===Depression===
A Duke University pilot study compared treatment of depression by antidepressant medication to treatment by antidepressants and dialectical behavior therapy. A total of 34 chronically depressed individuals over age 60 were treated for 28 weeks. Six months after treatment, statistically significant differences were noted in remission rates between groups, with a greater percentage of patients treated with antidepressants and dialectical behavior therapy in remission.<ref name="Lynch">{{Cite journal |last=Lynch |first=Thomas |date=January–February 2003 |title=Dialectical Behavior Therapy for Depressed Older Adults: A Randomized Pilot Study |journal=The American Journal of Geriatric Psychiatry |volume=11 |issue=1 |pages=33–45 |doi=10.1097/00019442-200301000-00006 |pmid=12527538}}</ref>{{Primary source inline|reason=MEDRS prefers review articles|date=June 2021}}

=== Complex post-traumatic stress disorder (CPTSD)===
Exposure to [[Complex post-traumatic stress disorder|complex trauma]], or the experience of prolonged trauma with little chance of escape, can lead to the development of complex post-traumatic stress disorder (CPTSD) in an individual.<ref name=":1">{{Cite journal |last1=Heide |first1=F. Jackie June ter |last2=Mooren |first2=Trudy M. |last3=Kleber |first3=Rolf J. |date=February 12, 2016 |title=Complex PTSD and phased treatment in refugees: a debate piece |journal=European Journal of Psychotraumatology |language=en |volume=7 |issue=1 |pages=28687 |doi=10.3402/ejpt.v7.28687 |issn=2000-8198 |pmc=4756628 |pmid=26886486}}</ref> The [[American Psychiatric Association]] (APA) does not recognize CPTSD as a diagnosis in the [[Diagnostic and Statistical Manual of Mental Disorders|DSM]]-5 (Diagnostical and Statistical Manual of Mental Disorders, the manual used by providers to diagnose, treat and discuss mental illness), though many practitioners argue that CPTSD is separate from [[Posttraumatic stress disorder|post-traumatic stress disorder]] (PTSD).<ref>{{Cite journal |last=Bryant |first=Richard A. |date=August 2010 |title=The Complexity of Complex PTSD |journal=American Journal of Psychiatry |language=en |volume=167 |issue=8 |pages=879–881 |doi=10.1176/appi.ajp.2010.10040606 |issn=0002-953X |pmid=20693462}}</ref> As of 2020, over 40 studies from 15 different countries had "consistently demonstrated the distinction between PTSD and CPTSD" and "replicated the distinct symptoms associated with each disorder" according to a 2021 literature review.<ref>{{Cite journal |last=Cloitre |first=Marylene |date=2021-02-01 |title=Complex PTSD: assessment and treatment |journal=European Journal of Psychotraumatology |language=en |volume=12 |issue=sup1 |doi=10.1080/20008198.2020.1866423 |issn=2000-8066 |pmc=8018425}}</ref>

CPTSD is similar to PTSD in that its symptomatology is pervasive and includes cognitive, emotional, and biological domains, among others.<ref name=":2">{{Cite journal |last=Olson-Morrison |first=Debra |year=2017 |title=Integrative play therapy with adults with complex trauma: A developmentally-informed approach. |journal=International Journal of Play Therapy |language=en |volume=26 |issue=3 |pages=172–183 |doi=10.1037/pla0000036 |issn=1939-0629}}</ref> CPTSD differs from PTSD in that it is believed to originate in childhood interpersonal trauma, or chronic childhood stress,<ref name=":2" /> and that the most common precedents are sexual traumas.<ref name=":3">{{Cite journal |last1=Maercker |first1=Andreas |last2=Hecker |first2=Tobias |last3=Augsburger |first3=Mareike |last4=Kliem |first4=Sören |date=January 2018 |title=ICD-11 Prevalence Rates of Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in a German Nationwide Sample |journal=The Journal of Nervous and Mental Disease |volume=206 |issue=4 |pages=270–276 |doi=10.1097/nmd.0000000000000790 |issn=0022-3018 |pmid=29377849 |s2cid=4438682}}</ref> Currently, the prevalence rate for CPTSD is an estimated 0.5%, while PTSD's is 1.5%.<ref name=":3" /> Numerous definitions for CPTSD exist. Different versions are contributed by the World Health Organization ([[World Health Organization|WHO]]), The International Society for Traumatic Stress Studies ([[International Society for Traumatic Stress Studies|ISTSS]]), and individual clinicians and researchers.

Most definitions revolve around criteria for PTSD with the addition of several other domains. While The APA may not recognize CPTSD, the WHO has recognized this syndrome in its 11th edition of the [[International Classification of Diseases]] (ICD-11). The WHO defines CPTSD as a disorder following a single or multiple events which cause the individual to feel stressed or trapped, characterized by low self-esteem, interpersonal deficits, and deficits in affect regulation.<ref>https://www.who.int/standards/classifications/classification-of-diseases} {{bare URL inline|date=February 2024}}</ref> These deficits in affect regulation, among other symptoms are a reason why CPTSD is sometimes compared with [[borderline personality disorder]] (BPD).

==== Similarities Between CPTSD and borderline personality disorder ====
In addition to affect dysregulation, case studies reveal that patients with CPTSD can also exhibit splitting, mood swings, and fears of abandonment.<ref name=":4">{{Cite journal |last=Lawson |first=David M. |date=June 21, 2017 |title=Treating Adults With Complex Trauma: An Evidence-Based Case Study |journal=Journal of Counseling & Development |language=en |volume=95 |issue=3 |pages=288–298 |doi=10.1002/jcad.12143 |issn=0748-9633}}</ref> Like patients with borderline personality disorder, patients with CPTSD were traumatized frequently and/or early in their development and never learned proper coping mechanisms. These individuals may use avoidance, substances, dissociation, and other maladaptive behaviors to cope.<ref name=":4" />{{Better source needed|reason=Arguably poor to make general statements about CPTSD sufferers supported by a single case study ([[WP:NOTRS]]).|date=June 2023}} Thus, treatment for CPTSD involves stabilizing and teaching successful coping behaviors, affect regulation, and creating and maintaining interpersonal connections.<ref name=":4" /> 
In addition to sharing symptom presentations, CPTSD and BPD can share neurophysiological similarities, for example, abnormal volume of the amygdala (emotional memory), hippocampus (memory), anterior cingulate cortex (emotion), and orbital prefrontal cortex (personality).<ref name=":5">{{Cite journal |last1=Ford |first1=Julian D |last2=Courtois |first2=Christine A |year=2014 |title=Complex PTSD, affect dysregulation, and borderline personality disorder |journal=Borderline Personality Disorder and Emotion Dysregulation |language=En |volume=1 |issue=1 |pages=9 |doi=10.1186/2051-6673-1-9 |issn=2051-6673 |pmc=4579513 |pmid=26401293 |doi-access=free }}</ref> Another shared characteristic between CPTSD and BPD is the possibility for dissociation. Further research is needed to determine the reliability of dissociation as a hallmark of CPTSD, however it is a possible symptom.<ref name=":5" /> Because of the two disorders' shared symptomatology and physiological correlates, psychologists began hypothesizing that a treatment which was effective for one disorder may be effective for the other as well.

==== DBT as a treatment for CPTSD ====
DBT's use of acceptance and goal orientation as an approach to behavior change can help to instill empowerment and engage individuals in the therapeutic process. The focus on the future and change can help to prevent the individual from becoming overwhelmed by their history of trauma.<ref>{{Cite journal |last1=Fasulo |first1=Samuel J. |last2=Ball |first2=Joanna M. |last3=Jurkovic |first3=Gregory J. |last4=Miller |first4=Alec L. |date=April 2015 |title=Towards the Development of an Effective Working Alliance: The Application of DBT Validation and Stylistic Strategies in the Adaptation of a Manualized Complex Trauma Group Treatment Program for Adolescents in Long-Term Detention |journal=American Journal of Psychotherapy |volume=69 |issue=2 |pages=219–239 |doi=10.1176/appi.psychotherapy.2015.69.2.219 |issn=0002-9564 |pmid=26160624 |doi-access=free}}</ref> This is a risk especially with CPTSD, as multiple traumas are common within this diagnosis. Generally, care providers address a client's suicidality before moving on to other aspects of treatment. Because PTSD can make an individual more likely to experience suicidal ideation,<ref name=":6">{{Cite journal |last1=Krysinska |first1=Karolina |last2=Lester |first2=David |date=January 29, 2010 |title=Post-Traumatic Stress Disorder and Suicide Risk: A Systematic Review |journal=Archives of Suicide Research |language=en |volume=14 |issue=1 |pages=1–23 |doi=10.1080/13811110903478997 |issn=1381-1118 |pmid=20112140 |s2cid=10827703}}</ref> DBT can be an option to stabilize suicidality and aid in other treatment modalities.<ref name=":6" />

Some critics argue that while DBT can be used to treat CPTSD, it is not significantly more effective than standard PTSD treatments. Further, this argument posits that DBT decreases self-injurious behaviors (such as cutting or burning) and increases interpersonal functioning but neglects core CPTSD symptoms such as impulsivity, [[Schema (psychology)|cognitive schemas]] (repetitive, negative thoughts), and emotions such as guilt and shame.<ref name=":5" /> The ISTSS reports that CPTSD requires treatment which differs from typical PTSD treatment, using a multiphase model of recovery, rather than focusing on traumatic memories.<ref name=":1" /> The recommended multiphase model consists of establishing safety, distress tolerance, and social relations.<ref name=":1" />

Because DBT has four modules which generally align with these guidelines (Mindfulness, Distress Tolerance, Affect Regulation, Interpersonal Skills) it is a treatment option. Other critiques of DBT discuss the time required for the therapy to be effective.<ref name=":7">{{Cite journal |last1=Landes |first1=Sara J. |last2=Garovoy |first2=Natara D. |last3=Burkman |first3=Kristine M. |date=March 25, 2013 |title=Treating Complex Trauma Among Veterans: Three Stage-Based Treatment Models |journal=Journal of Clinical Psychology |language=en |volume=69 |issue=5 |pages=523–533 |doi=10.1002/jclp.21988 |issn=0021-9762 |pmid=23529776}}</ref> Individuals seeking DBT may not be able to commit to the individual and group sessions required, or their insurance may not cover every session.<ref name=":7" />

A study co-authored by Linehan found that among women receiving outpatient care for BPD and who had attempted suicide in the previous year, 56% additionally met criteria for PTSD.<ref>{{Cite journal |last1=Harned |first1=Melanie S. |last2=Rizvi |first2=Shireen L. |last3=Linehan |first3=Marsha M. |date=October 2010 |title=Impact of Co-Occurring Posttraumatic Stress Disorder on Suicidal Women With Borderline Personality Disorder |url=http://psychiatryonline.org/doi/abs/10.1176/appi.ajp.2010.09081213 |journal=American Journal of Psychiatry |language=en |volume=167 |issue=10 |pages=1210–1217 |doi=10.1176/appi.ajp.2010.09081213 |issn=0002-953X |pmid=20810470|url-access=subscription }}</ref> Because of the correlation between borderline personality disorder traits and trauma, some settings began using DBT as a treatment for traumatic symptoms.<ref name=":9">{{Cite journal |last1=Steil |first1=Regina |last2=Dittmann |first2=Clara |last3=Müller-Engelmann |first3=Meike |last4=Dyer |first4=Anne |last5=Maasch |first5=Anne-Marie |last6=Priebe |first6=Kathlen |date=January 2018 |title=Dialectical behaviour therapy for posttraumatic stress disorder related to childhood sexual abuse: a pilot study in an outpatient treatment setting |journal=European Journal of Psychotraumatology |language=en |volume=9 |issue=1 |pages=1423832 |doi=10.1080/20008198.2018.1423832 |issn=2000-8198 |pmc=5774406 |pmid=29372016}} &ndash; Describes a trial of the DBT-PTSD protocol, described in more detail in: {{cite book |last1=Bohus |first1=Martin |last2=Priebe |first2=Kathlen |chapter=DBT–PTSD: A Treatment Programme for Complex PTSD After Childhood Abuse |title=The Oxford Handbook of Dialectical Behaviour Therapy |date=2018 |pages=814–828 |doi=10.1093/oxfordhb/9780198758723.013.48}}</ref> Some providers opt to combine DBT with other PTSD interventions, such as [[prolonged exposure therapy]] (PE) (repeated, detailed description of the trauma in a psychotherapy session)<ref>{{cite book |last1=Harned |first1=Melanie S. |title=Treating trauma in dialectical behavior therapy: the DBT prolonged exposure protocol (DBT PE) |date=2022 |publisher=The Guilford Press |location=New York |isbn=9781462549122}}</ref> or [[cognitive processing therapy]] (CPT) (psychotherapy which addresses cognitive schemas related to traumatic memories).{{citation needed|date=September 2024}}

For example, a regimen which combined PE and DBT would include teaching mindfulness skills and distress tolerance skills, then implementing PE. The individual with the disorder would then be taught acceptance of a trauma's occurrence and how it may continue to affect them throughout their lives.<ref name=":8">{{Cite journal |last1=Meyers |first1=Laura |last2=Voller |first2=Emily K. |last3=McCallum |first3=Ethan B. |last4=Thuras |first4=Paul |last5=Shallcross |first5=Sandra |last6=Velasquez |first6=Tina |last7=Meis |first7=Laura |date=March 22, 2017 |title=Treating Veterans With PTSD and Borderline Personality Symptoms in a 12-Week Intensive Outpatient Setting: Findings From a Pilot Program |journal=Journal of Traumatic Stress |language=en |volume=30 |issue=2 |pages=178–181 |doi=10.1002/jts.22174 |issn=0894-9867 |pmid=28329406}}</ref><ref name=":9" /> Participants in clinical trials of this DBT PE regimen exhibited a decrease in symptoms, and throughout the 12-week trial, no self-injurious or suicidal behaviors were reported.<ref name=":8" /> Later trials similarly show increased effectiveness versus DBT.<ref>{{cite journal |last1=Harned |first1=MS |last2=Schmidt |first2=SC |last3=Korslund |first3=KE |last4=Gallop |first4=RJ |title=Does Adding the Dialectical Behavior Therapy Prolonged Exposure (DBT PE) Protocol for PTSD to DBT Improve Outcomes in Public Mental Health Settings? A Pilot Nonrandomized Effectiveness Trial With Benchmarking. |journal=Behavior Therapy |date=May 2021 |volume=52 |issue=3 |pages=639–655 |doi=10.1016/j.beth.2020.08.003 |pmid=33990239 |pmc=8124086}}</ref>

Another argument which supports the use of DBT as a treatment for trauma hinges upon PTSD symptoms such as emotion regulation and distress. Some PTSD treatments such as exposure therapy may not be suitable for individuals whose distress tolerance and/or emotion regulation is low.<ref name=":10">{{Cite journal |last1=Wagner |first1=Amy W. |last2=Rizvi |first2=Shireen L. |last3=Harned |first3=Melanie S. |year=2007 |title=Applications of dialectical behavior therapy to the treatment of complex trauma-related problems: When one case formulation does not fit all |journal=Journal of Traumatic Stress |language=en |volume=20 |issue=4 |pages=391–400 |doi=10.1002/jts.20268 |issn=0894-9867 |pmid=17721961}}</ref> [[Biosocial theory]] posits that emotion dysregulation is caused by an individual's heightened emotional sensitivity combined with environmental factors (such as invalidation of emotions, continued abuse/trauma), and tendency to [[Rumination (psychology)|ruminate]] (repeatedly think about a negative event and how the outcome could have been changed).<ref name=":11">{{Cite journal |last1=Florez |first1=Ivonne Andrea |last2=Bethay |first2=J. Scott |date=January 13, 2017 |title=Using Adapted Dialectical Behavioral Therapy to Treat Challenging Behaviors, Emotional Dysregulation, and Generalized Anxiety Disorder in an Individual With Mild Intellectual Disability |journal=Clinical Case Studies |language=en |volume=16 |issue=3 |pages=200–215 |doi=10.1177/1534650116687073 |issn=1534-6501 |s2cid=151755852}}</ref>

An individual who has these features is likely to use maladaptive coping behaviors.<ref name=":11" /> DBT can be appropriate in these cases because it teaches appropriate coping skills and allows the individuals to develop some degree of self-sufficiency.<ref name=":11" /> The first three modules of DBT increase distress tolerance and emotion regulation skills in the individual, paving the way for work on symptoms such as intrusions, self-esteem deficiency, and interpersonal relations.<ref name=":10" />

Noteworthy is that DBT has often been modified based on the population being treated. For example, in veteran populations DBT is modified to include exposure exercises and accommodate the presence of [[traumatic brain injury]] (TBI), and insurance coverage (i.e. shortening treatment).<ref name=":8" /><ref name=":13">{{Cite journal |last1=Denckla |first1=Christy A. |last2=Bailey |first2=Robert |last3=Jackson |first3=Christie |last4=Tatarakis |first4=John |last5=Chen |first5=Cory K. |date=November 2015 |title=A Novel Adaptation of Distress Tolerance Skills Training Among Military Veterans: Outcomes in Suicide-Related Events |journal=Cognitive and Behavioral Practice |volume=22 |issue=4 |pages=450–457 |doi=10.1016/j.cbpra.2014.04.001 |issn=1077-7229}}</ref> Populations with [[Comorbidity|comorbid]] BPD may need to spend longer in the "Establishing Safety" phase.<ref name=":5" /> In adolescent populations, the skills training aspect of DBT has elicited significant improvement in emotion regulation and ability to express emotion appropriately.<ref name=":13" /> In populations with comorbid substance use, adaptations may be made on a case-by-case basis.<ref name=":14">{{Cite journal |last=Litt |first=Lisa |date=March 26, 2013 |title=Clinical Decision Making in the Treatment of Complex PTSD and Substance Misuse |journal=Journal of Clinical Psychology |language=en |volume=69 |issue=5 |pages=534–542 |doi=10.1002/jclp.21989 |issn=0021-9762 |pmid=23533007}}</ref>

For example, a provider may wish to incorporate elements of [[motivational interviewing]] (psychotherapy which uses empowerment to inspire behavior change). The degree of substance use should also be considered. For some individuals, substance use is the only coping behavior they know, and as such the provider may seek to implement skills training before targeting substance reduction. Inversely, a client's substance use may be interfering with attendance or other treatment compliance and the provider may choose to address the substance use before implementing DBT for the trauma.<ref name=":14" />

==See also==
{{Portal|Psychology|Society|Education}}
<!-- Alphabetical order please -->
<!-- Please add a short description [[WP:SEEALSO]], via {{subst:AnnotatedListOfLinks}} or {{Annotated link}} -->
* {{Annotated link |Acceptance and commitment therapy}}
* {{Annotated link |Behaviour therapy}}
* {{Annotated link |Cognitive emotional behavioral therapy}}
* {{Annotated link |Mentalization-based treatment}}
* {{Annotated link |Nonviolent Communication}}
* {{Annotated link |Rational emotive behavior therapy}}
* {{Annotated link |Social skills}}

==References==
=== Citations ===
{{Reflist}}

=== General and cited sources ===
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* {{Cite journal |last1=Linehan |first1=M.M. |last2=Comtois |first2=K.A. |last3=Murray |first3=A.M. |last4=Brown |first4=M.Z. |last5=Gallop |first5=R.J. |last6=Heard |first6=H.L. |last7=Korslund |first7=K.E. |last8=Tutek |first8=D.A. |last9=Reynolds |first9=S.K. |last10=Lindenboim |first10=N. |year=2006 |title=Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder |journal=Arch Gen Psychiatry |volume=63 |issue=7 |pages=757–66 |doi=10.1001/archpsyc.63.7.757 |pmid=16818865 |doi-access=free}}
* {{Cite journal |last1=Linehan |first1=M.M. |last2=Dimeff |first2=L.A. |last3=Reynolds |first3=S.K. |last4=Comtois |first4=K.A. |last5=Welch |first5=S.S. |last6=Heagerty |first6=P. |last7=Kivlahan |first7=D.R. |year=2002 |title=Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder |journal=Drug and Alcohol Dependence |volume=67 |issue=1 |pages=13–26 |doi=10.1016/s0376-8716(02)00011-x |pmid=12062776}}
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* {{Cite journal |last1=Linehan |first1=M.M. |last2=Tutek |first2=D.A. |last3=Heard |first3=H.L. |last4=Armstrong |first4=H.E. |year=1994 |title=Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients |journal=American Journal of Psychiatry |volume=151 |issue=12 |pages=1771–1776 |doi=10.1176/ajp.151.12.1771 |pmid=7977884}}
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* {{Cite journal |last1=van den Bosch |first1=L.M.C. |last2=Verheul |first2=R. |last3=Schippers |first3=G.M. |last4=van den Brink |first4=W. |year=2002 |title=Dialectical Behavior Therapy of borderline patients with and without substance use problems: Implementation and long-term effects |journal=Addictive Behaviors |volume=27 |issue=6 |pages=911–923 |doi=10.1016/s0306-4603(02)00293-9 |pmid=12369475}}
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==Further reading==

=== Self-help ===
*{{cite book |title=DBT For Dummies |url=https://www.dummies.com/health/mental-health/dbt-for-dummies/ |last1=Galen |first1=Gillian |last2=Aguirre |first2=Blaise |year=2021 |isbn=978-1-119-73012-5|oclc=1191215618}}
* ''Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression & Anxiety'' by Thomas Marra. {{ISBN|978-1-57224-363-7}}.
* ''Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance (New Harbinger Self-Help Workbook)'' by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley. {{ISBN|978-1-57224-513-6}}.
* ''Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control (New Harbinger Self-Help Workbook)'' by Scott E. Spradlin. {{ISBN|978-1-57224-309-5}}.
* ''The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, & Validation '' by Alan E. Fruzzetti. {{ISBN|1-57224-450-X}}.

==External links==
{{Subject bar|auto=y|d=y}}
* {{Official website|https://wdbta.org|name=World Dialectical Behavior Therapy Association (WDBTA)}}
* {{Official website|https://dbt-lbc.org|name=Linehan Board of Certification (DBT-LBC)}}
{{Borderline personality disorder}}
{{Cognitive behavioral therapy}}
{{Psychotherapy}}
{{Authority control}}

[[Category:Borderline personality disorder]]
[[Category:Cognitive therapy]]
[[Category:Mindfulness (psychology)]]
[[Category:Psychotherapy by type]]