Learning Objectives: 

After reading this article, you should be able to: 

1. Understand Dialectical Behavior Therapy (DBT) and its components, including mindfulness, cognitive-behavioral therapy (CBT), acceptance-based therapy, and supportive case management.
2. Awareness of DBT skills, such as emotion regulation, distress tolerance, and interpersonal effectiveness, and their applications in addressing maladaptive behaviors.
3. Apply contingency management techniques in DBT, including reinforcing adaptive coping strategies and extinguishing crisis behaviors, to effectively manage challenging patient behaviors.

A young patient with borderline personality disorder (BPD) calls your office for the third time this week, reporting that she's started cutting again. You're discharging a middle-aged man with alcohol use disorder to residential treatment in another state, and you're concerned he might relapse on the plane. You're asked to consult on an orthopedic patient whose excessive demands have the entire surgical team feeling overwhelmed. How can you manage these situations effectively?

Dialectical behavior therapy (DBT) offers a set of tools that you can use in situations like these, regardless of your training background. Developed by psychologist Marsha Linehan to help patients with BPD (Cognitive Behavioral Therapy for Borderline Personality Disorder, Guilford Press, 1993), DBT has received strong empirical support over the past few decades (Tan, M. Y. L., McConnell, B., & Barlas, J. (2022). Application of Dialectical Behaviour Therapy in treating common psychiatric disorders: study protocol for a scoping review. BMJ open, 12(9), e058565. https://doi.org/10.1136/bmjopen-2021-058565). It has also proven effective for treating substance use disorders, eating disorders, depression, and even impulsive violence in correctional populations.

Understanding DBT 

DBT combines principles of mindfulness, cognitive-behavioral therapy (CBT), acceptance-based therapy, and supportive case management. It is a multimodal treatment that consists of weekly individual therapy, weekly DBT skills training, phone coaching, and a consultation team for DBT therapists. In DBT skills training, patients are taught a curriculum of skills, such as mindfulness and cognitive-behavioral techniques, to help them tolerate emotional distress and regulate emotions without resorting to self-harm. DBT phone coaching ensures that patients learn and apply more effective coping skills in daily life outside the context of therapy, and case management helps patients make necessary changes in their environments to reduce vulnerability for ongoing crisis behaviors.

As a therapist, the dialectical approach at the core of DBT can help you resolve two seemingly opposed positions: On the one hand, patients must learn to accept themselves, while on the other hand, they need to change behaviors that make their lives intolerable. This dialectic offers you a practical tool for understanding and managing challenging patient behavior. By assuming that patients are doing their best in any given moment, while also believing they can and will learn to do better, you can better increase your acceptance of the patient and be more effective in helping them change their current behaviors.

DBT skills 

DBT involves teaching patients new skills to replace maladaptive behaviors. By familiarizing yourself with these skills, you can tailor them to a patient's needs and teach them as needed (For a complete explanation of DBT skills along with training exercises and worksheets, see Linehan's DBT Skills Training Manual, Guilford Press, 2014). Most DBT skills are based on mindfulness, which teaches relaxation and greater awareness of the present moment. Mindfulness skills are considered foundational, core skills that underpin all skills in the DBT curriculum. The DBT mindfulness skills help patients increase their awareness of and engagement in the present moment, increase acceptance of reality just as it is, and increase their ability to control and direct their attention. In addition to the core mindfulness module, there are three additional modules of skills in DBT, including:

1. Emotion Regulation Skills build on mindfulness and include identifying and labeling emotions, understanding their connection to actions, and reducing vulnerability to emotional distress. The acronym "ABC PLEASE" reminds patients to take care of themselves by: Accumulating positive emotions; Building mastery, Coping ahead, treating Physical iLlness, Eating, Avoiding drugs, Sleeping, and Exercising. Using acronyms make emotion regulation skills easy to teach. Although these skills were conceived to help manage intense and labile moods, they also work well for patients struggling with addiction and managing environmental cues that can lead to relapse (Garland, E. L., & Howard, M. O. (2018). Mindfulness-based treatment of addiction: current state of the field and envisioning the next wave of research. Addiction science & clinical practice, 13(1), 14. https://doi.org/10.1186/s13722-018-0115-3).
2. Distress Tolerance Skills help patients increase their ability to tolerate emotional distress without engaging in crisis behaviors and minimize emotional suffering through reality acceptance skills.  They include distraction techniques such as pleasurable activities, pushing away unpleasant thoughts, and comparing oneself to people who are less fortunate. You can also teach patients to use intense sensations to distract from emotional distress, like squeezing ice cubes or snapping one's wrist with a rubber band, to help resist the urge to cut, burn or otherwise self-harm.
3. Interpersonal Effectiveness Skills involve helping patients analyze their goals in interpersonal situations and teaching them assertiveness and effective communication to achieve those goals. These skills take time to learn but can be helpful for coaching patients with work or relationship problems, or for inpatients who are having trouble negotiating with staff to get their needs met.

Contingency management

Contingency management is a key component of dialectical behavior therapy (DBT) that aims to reverse the reinforcement of maladaptive behavior often seen in traditional treatment. This approach focuses on examining the antecedents and consequences (such as rewards and punishments) associated with adaptive and maladaptive behaviors and then using behavioral principles increase the use of adaptive coping strategies and extinguish the use of crisis behaviors.

For example, instead of providing an urgent appointment for a patient who self-harms, traditional DBT denies access to their therapist for 24 hours. Conversely, adaptive behavior, such as using DBT skills instead of self-harming, is rewarded with the therapist's availability for phone consultations outside of regular hours.

As a therapist, you can apply contingency management in your everyday practice to provide appropriate care while managing challenging behaviors. In outpatient settings, consider offering walk-in hours or more frequent appointments for patients with BPD to ensure they receive care before reaching a crisis stage. For patients with a history of recurrent crises, reevaluate the inclination to hospitalize them after each instance of self-harm. Instead, offer voluntary hospitalization to patients who effectively use their safety plans, even if they have not yet self-harmed.

This customized reinforcement approach also works well in inpatient and consultation-liaison settings, where demanding patient behaviors can disrupt the entire ward. Patients who are told the call button is only for emergencies may escalate their behavior. A more effective approach is to schedule short visits from a nurse or behavioral health technician every hour or so, providing validation during these visits. This strategy can save time and reduce difficulties in the long run.

Validation 

To avoid making patients feel invalidated, provide generous validation as a DBT therapist. Invalidation refers to dismissing, minimizing or denying that a patient’s experience is real and true, and can result in patients feeling they are “wrong” for experiencing strong emotions or behaving in ways that, while ultimately self-defeating, are effective in reducing emotional pain temporarily. To counteract this, use statements acknowledging that patient’s behaviors made sense in the context of their experiences. For example, you might say, "I can see how, in that situation, it seemed like overdosing was the only way you could get anyone to listen to you." Validation can be effective in various circumstances, including when patients with BPD are in crisis, patients with addiction struggle to manage cravings, or when inpatients lash out at hospital staff.

Adapting DBT to different clinical situations 

DBT is adaptable and can be applied in a wide range of clinical situations. For instance, you can use DBT to treat eating disorders by incorporating targeted skills to address issues such as emotional eating, body image dissatisfaction, and perfectionism. In the context of substance use disorders, DBT helps patients develop coping strategies to deal with cravings, high-risk situations, and relapse prevention.

Furthermore, DBT has been adapted for use with adolescents, where it is called DBT for Adolescents (DBT-A). This version includes modifications to address the unique developmental needs and challenges faced by adolescents, such as family involvement, school-related issues, and the management of peer relationships (Rathus JH, Miller AL. DBT Skills Manual for Adolescents. New York: Guilford Press; 2015).

Conclusion

While not every DBT technique works for everyone, many therapists and their patients can find something helpful. By incorporating DBT skills and principles into your everyday clinical practice, you can enhance your ability to manage challenging situations and improve patient outcomes. The adaptability of DBT across a range of disorders and populations highlights its versatility and effectiveness as a therapeutic approach.

Additional DBT Resources

• For a thorough review of how to apply DBT principles in general practice, see Dimeff and Koerner, Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders and Settings, Guilford Press, 2007.
• Marsha Linehan’s DBT Skills Training Manual 2^nd Edition (Guilford Press, 2014) is a comprehensive resource for implementing DBT skills training.
• DBT Self Help (dbtselfhelp.com) is a website with information for patients and families that is written by people who have been through DBT.
• Dialecticalbehaviortherapy.com includes in-depth written descriptions and videos for learning and applying DBT skills.