A critique of Dialectical Behaviour Therapy (DBT) as a trauma intervention, examining its effectiveness, limitations, and impact on trauma recovery.
This paper aims to critique dialectical behaviour therapy (DBT). The first section discusses the basic principles of dialectics and the biosocial theory as well as the justifications for focusing on emotional regulation to attain a life worth living. The following section describes all the components of DBT and its strategies including the pre-treatment and four intervention stages, modes of therapy, and group skills. There are also special considerations when using this intervention for example, the vital and delicate therapeutic relationship and the modifications when using DBT with adolescents. Next, the critique of DBT highlights the benefits and limitations of the intervention and working with specific populations. Benefits include DBT being a transdiagnostic treatment and flexible to the client needs. The limitations expand on the lack of cross-cultural research and research using DBT with adolescents, as well as other implementation barriers. The final part of the critique compares DBT to other forms of trauma-informed psychotherapies regarding similarities, differences, and efficiency. Afterwards, recommendations are shared for future use DBT and training within the intervention strategy.
Linehan developed the dialectical behaviour therapy originally to chronic suicidal behaviour that is typically associated with borderline personality disorder (BPD) (Haft et al., 2022; MacPherson et al., 2013). It is not a transdiagnostic treatment approach for high-risk individuals with some of the most challenging mental health issues (Chugani et al., 2017). There is a plethora of information on DBT, as it is a thorough and well-researched approach. Therefore, details are spared regarding specific skills and homework options to provide an overall holistic body of information.
Dialectical philosophy, behavioural science, and Zen practice are the pillars of the theoretical approach (MacPherson et al., 2013). It also uses aspects of cognitive and acceptance strategies for change (Alba et al., 2022; Boritz et al., 2020). The dialectic aspect refers to the polarities between thoughts, actions, and behaviours, which may exist simultaneously causing friction and conflict in a person (MacPherson et al., 2013). Typical dialectical tensions include feelings and beliefs versus wise mind, good guy versus bad guy, and following rule versus reinforcing assertiveness (Linehan, 2015) The aim is to understand the polarities and how they are causing tension for a person to perform maladaptive behaviours like suicidal attempts, self-injury, and impulsivity (MacPherson et al., 2013).
The biosocial theory underlines the basic understanding problems associated with BPD. It posits that biological predisposition to impulsivity or emotional vulnerability, and invalidating environments resulting in emotional dysregulation (emotional vulnerability and inability to regulate emotions) (Alba et al., 2022; Boritz et al., 2020; Haft et al., 2022; Linehan, 2015; MacPherson et al., 2013). More generally, the biosocial theory provides answers to emotional dysregulation, associated problems, current coping mechanisms, identify relational dynamics, and potential alliance ruptures (Boritz et al., 2020)
DBT has five functions including increasing behavioural capacities, improving motivation, assuring for gains in the natural environment, establishing an environment to reinforce functioning, and attaining capabilities and motivation for therapists (MacPherson et al., 2013). These are carried throughout treatment. It is also important to note that target behaviours that are most dangerous and maladaptive that could result in ending one’s life or injuring themselves are prioritized in a hierarchy of what to address first in each stage (Alba et al., 2022; MacPherson et al., 2013). Further information on strategies is provided in the intervention outline.
DBT aims to replace maladaptive behaviours with adaptive behaviours in a validating environment (MacPherson et al., 2013). and improve goal orientation towards a life worth living (Boritz et al., 2020; MacPherson et al., 2013). Invalidating environments revolve around negative external reactions or treatment towards emotional displays and expression, which reinforces emotional escalation (MacPherson et al., 2013). For example, it is usually frequently communicated that the client was overreacting or wrong to react in that way (Alba et al., 2022) In turn, people raised in this environment have not learned how to label, regulate, or trust their emotions and emotional responses, tolerate distress, and typically rely on others to understand reality (MacPherson et al., 2013). This leads to excess of painful emotions, cognitive distortions, failures in information processing, lack of impulsive control, and emotional overcontrol or suppression (Linehan, 2015). Therefore, they look for other ways to relieve or eliminate tension like through suicide or non-suicide self-injurious (NSSI) behaviours (Alba et al., 2022). This contributes to their cycle of pain in attempting to manage their symptoms.
Core Strategies
The core strategies in DBT include validation (verbal and nonverbal), problem solving (applying reinforcing contingencies, natural reinforcers, shaping, extinction and punishment, and observing limits), cognitive restructuring, stylistic strategies (reciprocal communication and irreverent communication strategies), and core management strategies (client consultation and environmental intervention), and integrative strategies (ancillary treatments, crisis strategies, suicidal behaviour, and relationship problem solving strategies) (Linehan, 2015).
DBT Intervention Stages
The DBT intervention entails the following steps: the pre-treatment stage focuses on the therapeutic relationship, individualized treatment, and goals; stage one addresses and reduces maladaptive behaviours that are life-threatening, interfering with therapeutic relationship, and their quality of life to increase capabilities; the second stage aims to decrease post-traumatic stress symptoms and normalizing emotional regulation; the third stage targets increasing self-respect and achieving personalized goal(s); and the fourth stage finalizes feelings of wholeness and independency to maintain a sense of freedom and contentment (MacPherson et al., 2013). Each stage has prioritized hierarchy targets that are addressed with the four modes of therapy (MacPherson et al., 2013).
Modes of Therapy
The four modes of therapy are individual therapy, weekly group skills training, telephone coaching, and weekly therapist consultation meetings (MacPherson et al., 2013). Individual therapy is tailored to the prioritized behaviours that are present in session or reported through client’s homework tools regarding emotional regulation, problem behaviours, and skill usage (MacPherson et al., 2013). Weekly group skills training sessions last up to two and a half hours and have two leaders help with homework and teach new skills like mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness with various techniques (MacPherson et al., 2013). Telephone coaching lasts about five to ten minutes per call and happen as-needed regarding suicide or self-injurious urges Skills
Group skills training is taught over the course of six months and aims to eliminate therapy-destroying/interfering, and acquire, strengthen, and generalize skills (MacPherson et al., 2013). The four skill modules (mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness) are meant to address emotional regulation and associated problems (Haft et al., 2022). Moreover, diary cards are meant for clients to keep track of practicing skills and is part of standard homework reviews (Linehan, 2015).
Mindfulness is a vital skill in DBT that is used in every aspect of therapy to discover the truths between polarities by observing, describing, and participating (MacPherson et al., 2013). Some mindful skills include what and how core mindful skills, balancing doing mins and being mind, and wise mind walking the middle path (Linehan, 2015).
Distress tolerance is taught to cope and survive with bad situations, crises, and accepting situations in the face of helplessness through self-soothing strategies, distraction, and impulse control (MacPherson et al., 2013). Some distress tolerance skills include crisis survival, pros and cons, TIP skills, and self-soothing skills. (Linehan, 2015).
Emotional regulation occurs when one can label the emotion(s), assess the emotions appropriateness with current circumstances, modulating emotions, and increasing positive ones (MacPherson et al., 2013). Helpful emotional regulation skills: understanding and labeling emotions, checking the facts, and opposite action (Linehan, 2015).
Last, assertiveness skills aid in interpersonal effectiveness, which helps individuals achieve their goals through interactions while keeping the peace and upholding self-respect (MacPherson et al., 2013). Potential skills are DEAR MAN, GIVE, and FAST (Linehan, 2015).
Relational trauma, especially starting from childhood, often inhibits or negatively affects identity development and relational functioning, as inferences of the self and others, internal working models, implicit memories, and overall core schemas affect attachment styles and abilities to form relationships (Briere & Scott, 2015). Therefore, the therapeutic relationship can also be considered an intervention and a trauma trigger because it harbours an unfamiliar safe and trusting relationship (Briere & Scott, 2015; Boritz et al., 2020).
Building a strong and trusting therapeutic alliance can take a while with this population, but it vital before solidifying intervention processes (Briere & Scott, 2015). Therapists who demonstrate balancing of autonomy and control, nonjudgmental stance, and warmth have been linked to greater self-affirmation, self-love, self-protection, and less self-attack (MacPherson et al., 2013). In the event of crises regarding suicidal behaviour, the client is not allowed to call the therapist after an attempted suicide within 24 hours to ensure that there is no negative reinforcement in attempting the act for the therapist’s attention (MacPherson et al., 2013).
Another consideration is that there is a modified version of DBT for youth and adolescents, which incorporates family members in skills training and sessions, considers other adolescent-family dialectic dilemmas, a shorter treatment period, an optional graduate group, and a new skills module with modifications that are tailored to adolescent development needs (MacPherson et al., 2013).
Since emotional dysregulation is a common denominator across various psychopathologies, DBT has resulted in positive treatment results for adults and adolescents not only BPD, but also depression, eating disorders (ED), attention-deficit/hyperactivity disorder (ADHD), trichotillomania (TTC), bipolar disorder (BD), substance abuse disorder, oppositional defiant disorder (ODD) (MacPherson et al., 2013), post-traumatic stress disorder (PTSD) (Haft et al., 2022), and complex PTSD (CPTSD) (Schnaider et al., 2022). BPD and PTSD are common comorbid diagnoses (Snoek et al., 2020). BPD, somatization disorder, and multiple personality disorder have many overlapping symptoms that are commonly misdiagnosed and majority of the time there has been exposure to trauma and emotional dysregulation (Herman, 2015). Moreover, the same commonalities are between PTSD comorbid with BPD, and CPTSD (Cyr et al., 2022). Due to their underlying commonality of emotional dysregulation due to trauma, these overlaps, although difficult to diagnose, can be treated similarly by DBT.
DBT has empirical support for reducing NSSI, suicide ideation, severity of suicidal behaviour, hopelessness, depression, anger/irritability, aggression, health service utilization, inpatient psychiatric days, and symptoms related to specific disorders mentioned above (MacPherson et al., 2013). Moreover, DBT treatments are flexible and effective in various environments including inpatient units, community mental health centers, and forensic settings (MacPherson et al., 2013).
There is a lack of research regarding DBT for adolescents and the research obtained lacks comparison groups, which make it difficult to pinpoint whether improvements are directly linked to specific DBT factors (MacPherson et al., 2013). Additionally, there is a lack of research regarding DBT and other races, ethnicities, and cultures (Haft et al., 2022). This is a particular problem because suicide rate differs cross-culturally and by race and ethnicity, plus suicide risk factors and intervention are likely different (Haft et al., 2022). Fortunately, DBT is thorough in assessments and flexible, which makes it adaptable to various cultural goals and needs, nonetheless, there is a need for mor cross-cultural research (Haft et al., 2022).
Furthermore, there are some general concerns about the implementation about DBT including unbillable clinician time (training, consultation meetings, telephone coaching), staff turnover (especially in mental health communities where the almost half of clients do not finish DBT training), lack of organization support, a lack of planning and resources for implementation, time constraints, and interpersonal issues regarding team dynamics for consultations (Chugani et al., 2017). These issues can be linked to the extensive and lengthy process of DBT (Snoek et al., 2020). The concerns are adjacent strengths when using DBT strategies. For example, although work may be unbillable, phone coaching is helpful to counter urges the client must commit suicide, helps with organization skills, and aid the therapeutic relationship (Alba et al., 2022). Likewise, team consultations are helpful for the client and the therapist to receive support (Alba et al., 2022).
There is a common understanding that emotional regulation is at the core of developing healthy coping skills to decrease and/or eliminate PTSD symptoms (Schnaider et al., 2022). Trauma-focused cognitive behavioural therapies (TF-CBT) are ideal for addressing and treating emotional dysregulation (Schnaider et al., 2022), which includes TF-CBT, cognitive processing theory (CPT) (Schnaider et al., 2022), Skills training in affective and interpersonal regulation with narrative therapy (SNT) (Cloitre, 2013; Cloitre et al., 2017); and DBT (MacPherson et al., 2013).
One of the biggest differences between DBT and other strategies is the pre-treatment phase and the lengths DBT strategies go to ensure safety and stabilization for a client. DBT was meant to address life-threatening behaviours through emotional regulation in BPD clients, therefore, the pre-treatment phase is vital to ensure stabilization and build necessary skills to engage in exposure of trauma (MacPherson et al., 2013). This strategy follows the three-phased based approach, where the first stage targets stabilization, the second is for trauma exposure and coping, and the third is reconnecting and strengthening coping skills (Herman, 2015; Schnaider et al., 2022).
It is common for a client receiving DBT to wait 12 months before engaging with trauma exposure (Snoek et al., 2020). There are arguments that time, preparation, and focus on emotional regulation is not necessary for a client to be successful with trauma exposure. A study found that using CPT in combination with prolonged exposure (PE) can improve emotional regulation skills and decrease PTSD symptoms associated with trauma simultaneously (Schanider et al., 2022). Moreover, eye movement desensitization and reprocessing (EMDR) therapy and TF-CBT are known to best treat PTSD (Bilal et al., 2015). In comparison with DBT, EMDR has evidence that it is more cost-effective and time saving with similar improvements regarding trauma symptoms (Snoek et al., 2020).
The combination of EMDR and DBT could be the most effective and a quicker recovery time (Snoek et al., 2020). Moreover, there is evidence that supports DBT skills training to be effective on its own (Haft et al., 2022). Perhaps DBT in combination with other exposure focused interventions could generally help with efficiency. Nonetheless, the downsides of being less effective for PTSD treatment, is the upside for treatment with suicide ideation, suicide attempts, and NSSI (Alba et al., 2022).
Another difference is that DBT emphasizes on working in a team (Alba et al., 2022). Working on a team helps to ensure that DBT strategies are being tailored specifically to the client in an efficient way and motivating and supporting one another acting as a protective factor to burnout and compassion fatigue (Alba et al., 2022). Other approaches may work with a client’s circle of care when needed, but they are not incorporated into the treatment.
Furthermore, core similarities exist between SNT and DBT, as they both focus on emotional regulation and interpersonal skills with behavioural activation methods (Cloitre et al., 2017; Macpherson et al., 2013). Moreover, DBT shares commonalities in other trauma-informed psychotherapies that centralize mindfulness into their approach like mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), mindfulness-based relapse prevention (MBRP), and acceptance commitment therapy (ACT) (Briere & Scott, 2015).
Regarding the developing the delicate therapeutic relationship, it is recommended to use an alliance-focused lens to DBT that requires observing for active-passivity, patterns or withdrawal or avoidance and then responding with continuous validation of emotions attached to the behaviour while also pushing the client to work through the discrepancies with the therapist (Boritz et al., 2020). By repeatedly doing this with clients, it can decrease the chances of withdrawal ruptures and increases the chance of them actively confronting and pushing through the avoidance urges (Boritz et al., 2020).
To address barrier and efficiency concerns, the barriers to implementation (BTI) tool and the BTI scale (BTI-s) are used to measure the DBT program implementation (Chugani et al., 2017). Reading about various results and using the BTS-S (using caution while interpreting results) for variations in self-designed DBT programs can aid the clinician in being mindful of the limitations and adjust the program accordingly. This could reduce the time needed to establish stabilization and safety in the pre-treatment stage. More research is required.
A recommendation to incorporate cultural concerns is to implement language consistency across all measures including team consultations, have open discussions about stigma, historical and intergenerational trauma, racism, prejudice, acculturation stress, and discrimination should be incorporated into treatment, as well as opening to somatic ways of expressing emotions with client from non-western, educated, industrialized, rich, democratic contexts, (Haft et al., 2022). Moreover, when interpersonal effectiveness skills are being taught, a pre-discussion, like using a DBT worksheet about the pros and cons of interpersonal skills before culturally adapting DEAR MAN and FAST interventions, should be used to guide training (Haft et al., 2022).
DBT specializes in treating clients with BPD especially with life-threatening behaviours but is a transdiagnostic treatment due to its focus on emotional regulation and interpersonal effectiveness. All clients are unique, therefore combining DBT with other exposure focused interventions could be beneficial. More research is needed to add to its flexibility and versatility.
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Snoek, A., Beekman, A. T. F., Dekker, J., Aarts, I., van Grootheest, G., Blankers, M., Vriend, C., van den Heuvel, O., & Thomaes, K. (2020). A randomized controlled trial comparing the clinical efficacy and cost-effectiveness of eye movement desensitization and reprocessing (EMDR) and integrated EMDR-Dialectical Behavioural Therapy (DBT) in the treatment of patients with post-traumatic stress disorder and comorbid (Sub)clinical borderline personality disorder: study design. BMC Psychiatry, 20(1), 1–18. https://doi.org/10.1186/s12888-020-02713-x
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