Dialectical Behavior Therapy (Trauma, Anxiety, Depression, Bi-Polar)
Dealing with mental health issues is a complicated and oftentimes costly endeavor. Common problems such as therapeutic disagreements, high cost and overly prolonged treatment periods come in the way of many looking for a straightforward fix to their issues. Dialectical Behavior Therapy is a multicomponent psychosocial intervention proven to treat various mental health conditions. Furthermore, systematic reviews on the therapy have shown that it is exceptionally cost-effective and reduces pathological symptoms over a short period of treatment (Murphy et al., 2020; DeCou et al., 2019). Suppose you are struggling with mental health issues and do not respond well to arduous sessions of the typical cognitive-behavioral style therapies. In that case, Dialectical Behavior Therapy will be a good treatment choice that possesses strong guarantees of treatment success. In the following article, we will highlight the science behind Dialectical Behavior Therapy and overview its success rate for treating trauma, anxiety, depression and bipolar.
Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) is a cognitive behavioral-based talking therapy that was initially developed for treating chronic suicidality and borderline personality disorder (BPD) (Linehan et al., 1991). Essentially, it targets disorders associated with an inability to manage emotions and regulate feelings. Similar to cognitive-behavioral therapy (CBT), which aims to reformulate dysfunctional thought patterns in the patient, DBT undertakes this process but integrates an aspect of self-acceptance that improves the regulation of distressing emotions. The word ‘dialectical’ is representative of DBT’s primary tenets. It corresponds to the concept that an individual possesses two distinct beliefs or thoughts that can appear to conflict with each other but are simultaneously valid. These are:
Accepting yourself and your emotions (Acceptance)
Changing your behavior to better yourself (Change)
Oftentimes, individuals who present themselves with Trauma or affective-based disorders (e.g., anxiety, depression and bi-polar) may be highly distressed due to the conflicting nature of their thoughts and behaviors. DBT essentially provides the framework to achieve acceptance and change, regardless of their conflicting nature, to drive cognitive and emotional rehabilitation in individuals suffering from these types of disorders. Over the years, DBT has moved past its original conception of treating chronic suicidality and BPD to amass a large evidence base in support of its treatment for disorders such as post-traumatic stress disorder (PTSD), depression, anxiety and bi-polar disorder. Subsequent review and meta-analytical studies have begun to break down and optimize DBT's underlying mechanisms of action for treatment (Yilmaz et al., 2022; Decou et al., 2019). At present, the evidence regarding the treatment of PTSD, depression, anxiety and bipolar is promising. Hence, we will highlight this throughout the article and overview the full nature of DBT's therapeutic impact on these respective disorders.
Post-Traumatic Stress Disorder
PTSD has been a historically difficult condition to treat. Alongside the apparent traumatic memories, PTSD symptomology consists of chronic anxiety, episodes of intense depression, guilt and oftentimes, rapid cycling of one negative emotion to another (Ehring & Quack, 2010). In consequence, due to its complex nature and the wide range of phenotypes (i.e., the set of observable symptoms) it possesses, clinicians must ascribe the relevant therapeutic mechanisms to target the specific symptoms. Moreover, individuals suffering from PTSD must accept and overcome a wide range of aversive emotions that are intensely experienced and arise spontaneously (Helzer, Robins & McEvoy, 1987). In that regard, DBT reliably demonstrates the ability to promote the radical acceptance of unchangeable emotions, thoughts and events surrounding trauma (Gorg et al., 2017). In addition, it significantly expedites the therapeutic process as patients undergoing treatment learn how to manage increased arousal during the confrontation of traumatic memories, which is a core element of recovery from PTSD.
DBT is also being actively applied in treating anxiety-based disorders, where it has accumulated substantial evidence for its role in reducing symptoms (Malivoire, 2020). Briefly defined, some core characteristics of anxiety consist of the emergence of unwanted internal experiences (e.g., emotions, thoughts, memories and bodily sensations) and the subsequent aversive cognitive response towards these internal events (Otte, 2022). Effectively, these two processes are in a reflexive relationship, meaning that they both negatively contribute to each other, creating a dysfunctional loop of thought and behavior. Within its treatment parameters, DBT possesses the relevant mechanisms of action that promote the appropriate regulation of intense anxiety-based symptoms (reference). Skills such as present moment focus, nonjudgmental awareness, and attentional flexibility are key processes imparted through DBT (Malivoire, 2020). Broadly, DBT integrates proponents of mindfulness and radical acceptance that have been shown to treat anxiety successfully as well as other anxiety-based disorders (e.g., Obsessive Compulsive Disorder and Social Anxiety Disorder) (reference).
Depression is an affective disorder characterized by highly negative thought patterns that drive most of its symptoms, including low mood, rumination (i.e., continuously thinking the same thoughts), mental fog and poor emotional processing (Fried et al., 2016). Moreover, for most depressed individuals, therapists can often ascribe a specific event or experience that has remained unaddressed and drives their negative symptoms (reference). Accordingly, these elements make depression extremely amenable to DBT’s primary mechanisms of action, which are to promote acceptance and cognitive-behavioral change (Linehan et al., 1991). Furthermore, DBT also integrates interpersonal effectiveness skills training which directly targets any symptoms that stem from deficits in psychosocial functioning, frequently present in depressive individuals (reference). Currently, most studies investigating the effectiveness of DBT for treating depression have shown positive results, many of which are concurrent with the levels of classical CBT for depression.
The inability to regulate emotions through psychological and physiological processes is a fundamental aspect of bipolar symptomology. This lack of emotional control may be due to the propensity of bipolar patients to experience more intense emotional episodes than the average person rendering their psychological state vulnerable to powerful mood swings. Studies have also shown that individuals suffering from bipolar often appraise emotional stimuli with predominantly negative responses, which diminishes the ability to appraise emotions through adaptive means (Johsnon et al., 2016). DBT was initially established as a treatment for BPD that targeted its symptoms of emotional dysregulation. Over the years, research has demonstrated that it can equally treat emotional dysregulation in bipolar disorder (Eisner et al., 2018). The theoretical framework that underlies DBT equates emotional dysregulation to a high level of emotional vulnerability (i.e., a sensitivity to negative emotions) coupled with a propensity to use maladaptive coping strategies (Linehan, 1993a). Through mindfulness, interpersonal functioning, and distress tolerance training, DBT successfully improves emotional regulation and provides the individual with adaptive coping strategies that alleviate many affective symptoms (reference).
The Bottom Line
DBT is highly beneficial for individuals living in a chaotic life, in constant fight or flight mode, and feeling emotions intensely. Accordingly, disorders such as PTSD, depression, anxiety and bipolar appear to be the most beneficially impacted by this treatment. For these individuals, remaining at a baseline level of emotional regulation is difficult. Through DBT treatment, they can adopt a roster of therapeutic skills that all aim to improve crucial elements of cognitive functioning. In essence, debilitating disorders such as PTSD or bipolar lock their victims into highly dysfunctional modes of thinking that require complex behavioral insights to break out from. DBT aims to impart you with the relevant tools and knowledge to break dysfunctional thought loops and optimize cognitive functioning. Its core tenets have been empirically supported, and DBT is currently used as a mainline form of therapy worldwide.
DeCou, C. R., Comtois, K. A., & Landes, S. J. (2019). Dialectical behavior therapy is effective for the treatment of suicidal behavior: A meta-analysis. Behavior therapy, 50(1), 60-72.
Eisner, L., Eddie, D., Harley, R., Jacobo, M., Nierenberg, A. A., & Deckersbach, T. (2017). Dialectical behavior therapy group skills training for bipolar disorder. Behavior therapy, 48(4), 557-566.
Ehring, T., & Quack, D. (2010). Emotion regulation difficulties in trauma survivors: The role of trauma type and PTSD symptom severity. Behavior therapy, 41(4), 587-598.
Fried, E. I., Epskamp, S., Nesse, R. M., Tuerlinckx, F., & Borsboom, D. (2016). What are'good'depression symptoms? Comparing the centrality of DSM and non-DSM symptoms of depression in a network analysis. Journal of affective disorders, 189, 314-320.
Görg, N., Priebe, K., Böhnke, J. R., Steil, R., Dyer, A. S., & Kleindienst, N. (2017). Trauma-related emotions and radical acceptance in dialectical behavior therapy for posttraumatic stress disorder after childhood sexual abuse. Borderline personality disorder and emotion dysregulation, 4(1), 1-12.
Helzer, J. E., Robins, L. N., & McEvoy, L. (1987). Post-traumatic stress disorder in the general population. New England Journal of Medicine, 317(26), 1630-1634.
Johnson, S. L., Tharp, J. A., Peckham, A. D., & McMaster, K. J. (2016). Emotion in bipolar I disorder: Implications for functional and symptom outcomes. Journal of abnormal psychology, 125(1), 40.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of general psychiatry, 48(12), 1060-1064.
Linehan, M. M. (1993). Dialectical behavior therapy for treatment of borderline personality disorder: implications for the treatment of substance abuse. NIDA research monograph, 137, 201-201.
Malivoire, B. L. (2020). Exploring DBT skills training as a treatment avenue for generalized anxiety disorder. Clinical Psychology: Science and Practice, 27(4), e12339.
Otte, C. (2022). Cognitive behavioral therapy in anxiety disorders: current state of the evidence. Dialogues in clinical neuroscience.
Yilmaz, S., Huguet, A., Kisely, S., Rao, S., Wang, J., Baur, K., ... & Wright, K. (2022). Do psychological interventions reduce symptoms of depression for patients with bipolar I or II disorder? A meta-analysis. Journal of Affective Disorders.