I have over 20 years of experience as a clinical social worker, serving in a variety of facilities in the state of Iowa. In my clinical work with patients, I apply a variety of different treatment modalities, each customized to the needs of the individual. For extremely unstable patients, and for those at risk of suicide or self-harm, I often employ dialectical behavior therapy (DBT). Developed in the 1970s and 1980s by psychologist Marsha M. Linehan, DBT grew out of her attempts to treat women suffering from borderline personality disorder. Linehan published the results of her work in a landmark paper in 1993, and she has further codified the approach over the subsequent years. Linehan developed DBT based on her experiences with standard cognitive behavioral therapy. In the process, she discovered several problems. First of all, the focus on personal change in cognitive behavioral therapy caused many of the women to drop out. As their emotional experiences were not recognized as legitimate by cognitive behavioral therapy, the constant admonition to change became demoralizing. Secondly, volatile patients often had control over therapists in cognitive behavioral therapy. Treatment providers were reluctant to breach topics that would lead to violent emotional outbursts by the patients, and patients learned to use such reactions to avoid topics they were uncomfortable with discussing. Finally, when dealing with suicidal, non-compliant patients, therapists simply did not have the time to conduct a thorough cognitive behavioral therapeutic approach. As a result, Linehan developed an approach that begins with an acceptance of the patient’s condition. Suicidal and violent tendencies are recognized as logical, if unhealthy, reactions, and through a variety of treatment steps, patients learn when to trust their emotional reactions. DBT attempts first to decrease high-risk behaviors such as suicide or self-harm, then reduce behaviors that prevent the therapy from being effective, and finally decrease those activities that negatively affect the patient’s quality of life. Subsequently, patients learn enhanced self-respect and how to efficiently deal with stressors in their lives. The process of DBT generally consists of four modules. In the Mindfulness module, the patient learns to pay attention to what is happening at any given moment. The Distress Tolerance module teaches patients how to adapt to difficult situations in their lives. For highly volatile individuals, the Emotional Regulation module helps them to develop control over their emotions. Finally, the Interpersonal Effectiveness module teaches patients how to better interact with other people. DBT has been the subject of a large body of rigorous clinical research involving randomized clinical trials, and it has been shown to lead to greater treatment retention than many other approaches when treating patients with borderline personality disorder or those who wish to harm themselves. DBT has also been used successfully to treat eating disorders and substance abuse.
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