Dialectical behavior therapy (DBT) was developed in the 1970s by Dr. Marsha Linehan to treat symptoms of what we call borderline personality disorder. A borderline personality is characterized by a fear of abandonment; chaotic relationships; chronic feelings of emptiness; reckless, impulsive, and self-injurious behaviors; and a constant roller coaster of emotions, including fits of rage. Before DBT came along, no approach seemed effective at treating these symptoms. At the time, DBT was revolutionary—there was finally a model that provided hope for emotional suffering (Linehan 1993).
So how was DBT able to accomplish what no other model could do? DBT works by teaching skills. DBT was, and still is, unique as a model of psychotherapy with its exclusive focus on skills work (Linehan 2014). Let’s consider a silly example of why this was such a simple yet powerful concept. Assume you have a friend learning to swim in the deep end of the pool. He is currently kicking and screaming, flailing and floundering…and quickly sinking. It is not going so well for your friend. What’s the best way to help? Well, if you wanted to use one approach to therapy, you could offer unconditional positive regard: “I believe in you! You’ve got this! You’re doing a great job!” If you wanted to use another approach, you could explore his thinking errors and determine that he is most likely catastrophizing, or imagining the worst possible outcome. If you wanted to use yet another approach, you could help him analyze his prior experiences with water, including any recent dreams about drowning. Or if you prefer to pursue a more practical approach, you could try to shape better behaviors in your friend by reinforcing any movement that (sort of) resembles a swim technique. Is your friend still sinking? Let’s try another approach: help your friend identify what gives his life meaning, especially since life is so fragile and finite.
I am being dramatic here, as all these approaches have their place. But right now, your friend does not need any of these interventions. Right now, what your friend needs is for someone to rescue him—and then teach the poor soul how to swim! That’s what DBT does. It teaches people skills to use when they feel like they are drowning in the deep end of life. Only then will the other approaches to therapy be useful and make any sense.
DBT works by teaching five simple yet profound skill sets: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and dialectics. Each of these terms will be elaborated on in the following chapters, but let’s introduce some basic working definitions to get us started. Mindfulness refers to awareness and acceptance of the moment. Distress tolerance refers to coping with a situation so that it does not become even worse. Emotion regulation refers to adopting a healthier lifestyle that will support healthier emotions. Interpersonal effectiveness involves how we deal with other people—communication, conflict, and all that drama. Finally, dialectics refers to looking at things from multiple perspectives and finding the middle path between two extremes (Linehan 2015).
Once the secret was out that DBT was effective in treating borderline personality disorder, people soon learned that DBT could be used to treat just about anything. Over the last few decades, DBT has been applied to pretty much anything that can be diagnosed: mood disorders, eating disorders, substance disorders, other personality disorders…you name it! (Ritschel et al. 2015).
Although never a substitute for appropriately prescribed medication, DBT has even been effective in mitigating organic disorders such as bipolar and schizophrenia. In other words, even with disorders in which there is literally something physically and chemically wrong with the brain, learning DBT skills can help people rewire their brain connections and find a more stable, healthier path through life (Van Dijk 2009; Mullen 2021).
This is good to know. Why? Because as you will learn, trauma is a disorder in which both the body and the brain are literally and physically thrown off balance. But unlike other disorders, there is no medication that can take away post-traumatic stress disorder (PTSD).There are some meds that can help reduce some of the symptoms of trauma, but there is no pill that can treat the trauma itself—so there better be some other options available!
So what about DBT? Is DBT effective in treating trauma symptoms? Well, of course. In fact, that’s the whole point of this book! However, the full response is more nuanced than that. Later in this chapter, we will talk much more about the causes and effects of trauma. Since its development in the 1970s, there has literally been a half century of research on trauma that Dr. Linehan did not have access to. To give you some perspective: the first airplane was flown in 1903; the first space shuttle landed on the moon in 1969. Clearly, a lot can happen in fifty plus years! We now know so much more about how trauma impacts every aspect of human functioning—thoughts, feelings, awareness, reactions, relationships—than ever before.
What is truly amazing about original DBT is how effective it has been in treating the majority of trauma symptoms—even before we had the massive body of research that we now have. For example, DBT’s emphasis on its five main skill sets directly targets many of the classic symptoms of PTSD related to avoidance, reactivity, self-blame, and dissociation. However, original DBT was never designed to treat symptoms of trauma related to reexperiencing the original trauma (such as nightmares and flashbacks).
In a nutshell, this is why DBT needs to be upgraded. This is why we need another book on DBT. And another book on trauma!
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