7 Dialectical Behavior Therapy CLIVE J. ROBINS AND M. ZACHARY ROSENTHAL
Dialectical behavior therapy (DBT) grew out of Marsha Linehan’s attempts in the 1970s and 1980s to apply the standard behavior therapy of that time (e.g., Goldfried & Davison, 1976), which had already demonstrated efficacy with a range of disorders, to chronically suicidal individuals (Linehan, 1987). The assumption was that suicidal behaviors are usually attempts to escape a life perceived to be not worth living, and therefore these individuals needed to develop skills not only to better tolerate emotional distress, but also to create a life that they do view as worth living. Helping patients learn these skills involved direct skills training through instruction, modeling, rehearsal, and coaching, as well as use of principles of reinforcement and exposure. However, these patients with multiple suicide attempts tend to be sensitive to criticism and prone to emotion dysregulation, and a strong focus only on change strategies can lead them to feel that their level of distress is not understood, or even that they are being blamed for their problems. They may respond with anger at the therapist or withdraw from treatment. On the other hand, letting go of an emphasis on change can lead the patient to feel that the therapist is not taking his or her pain seriously, which in turn may generate hopelessness or anger. In either case, the patient may feel invalidated. Research by Swann and his colleagues (e.g., Swann, Stein-Seroussi, & Giesler, 1992) demonstrates that invalidation of an individual’s basic self-constructs leads to increased emotional arousal, which in turn leads to cognitive dysregulation and impaired processing of new information. To help these patients, Linehan surmised that validation would have to play an important role in treatment. Clinical and empirical observations led Linehan to develop a treatment program that focuses not only on helping patients to make changes in their behaviors and environment, but also communicates acceptance of their current state and their environment, and integrates acceptance and change through a dialectical process. As most of the chronically suicidal individuals treated with this approach turned out to meet diagnostic criteria for borderline personality disorder (BPD), the treatment manuals were developed for that disorder (Linehan, 1993a, 1993b).
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