Dr Emily Fox on dialectical behaviour therapy 

As featured on Net Doctor, Dr Emily Fox takes an in-depth look into dialectical behaviour therapy (DBT), and why it's so important.

What is Dialectical Behaviour Therapy?
DBT is informally known as ‘talking therapy’. It is based around Cognitive Behavioural Therapy (CBT) but has been adapted to help people with extreme emotions.
Developed in the US by Psychologist Marsha Linehan, DBT was designed to treat people with a diagnosis of Borderline Personality Disorder, particularly individuals who had suicidal thoughts or attempts.

When developing DBT, Marsha Linehan pushed for a balance between acceptance and change, and recognised the importance of both validating the difficulty of a situation and pushing the individual to change. For example, trying to encourage a patient to accept the things they can’t change and finding the courage to change what they can. This tension between acceptance of things as they are in the moment and relentlessly pushing for change is a key component of DBT.

What are the modules?
There are four modules to DBT. The Skills Training Modules that are taught are Core Mindfulness, Emotion Regulation, Interpersonal Effectiveness and Distress Tolerance.

In DBT individuals are taught skills to enhance their capabilities in regulating emotions, managing relationships more effectively, tolerating distress and increasing awareness. Ensuring that the skills are acquired and then practiced and rehearsed is a key component of the comprehensive DBT programme.

What makes DBT different?
DBT relies on a team of people treating individual patients. Each member of the team brings different skills, knowledge and experience to the understanding of a specific behaviour. As a team we are far more likely to see the whole picture rather than a view held by any one individual. Ensuring that the team supports one another in order to avoid burnout, alongside ensuring that they stay true to the DBT principles is a core part of the comprehensive DBT programme.

How does it work?
Comprehensive DBT incorporates the following five functions:

  • Enhancing Capabilities – this involves teaching individuals new skills from the 4 modules outlined above (Core Mindfulness, Emotion Regulation, Interpersonal Effectiveness and Distress Tolerance).
  • Improving Motivation - this ensures individuals are using the skills to manage their problematic behaviours.
  • Ensuring Generalisation – in this function skills are taught so they can be used and transferred in all contexts, such as school, home, work and in the community.
  • Structuring the Environment – this function ensures that positive, adaptive behaviours are reinforced across all environmental settings.
  • Support for Therapists - because DBT is often provided to people who experience chronic, severe and intense mental health issues, this component ensures that therapists are supported to avoid them either burning out or having secondary stress reaction. It also allows them to focus, and not drift from the DBT principles.

The modes in which the functions are delivered vary dependent on the treatment setting – for example outpatient, inpatient, acute, long-stay etc.

How is it carried out?
DBT is not a one-hour-week therapy such as CBT or counselling, but involves a skills training component. This usually consists of two hours a week of group therapy, plus weekly individual therapy, and out-of-hours coaching. All DBT therapists should go to a consultation meeting every week.

Is it available on the NHS?
Yes, because DBT is such a complex and resource-intensive treatment it is mostly provided by the NHS and not often by individual practitioners.
The DBT programme at St Andrew’s started in 1999 and is well established. It was one of the first DBT programmes to be used in an inpatient setting in the UK.

There are also DBT programmes available in other private health sector providers. Independent mental health hospitals should indicate on their websites if they deliver DBT programmes.

Where can someone get DBT?
In the first instance, contact your local NHS Mental Health Trust to ask about the availability of DBT in your local health area. If DBT is not on offer locally, speak to your GP to find out if the NHS can find an out of area treatment package for you.

The Dialectical Behaviour Therapy Society in UK and Ireland has been accrediting therapists for the past four years. While they don’t have a full list of all DBT services provided in the UK (as membership of the Society for DBT is optional), the therapists that have been through their accreditation process can be found on their website (www.sfdbt.org).

Who is DBT suited to/designed for?
DBT is a recommended treatment by NICE (Clinical guideline [CG78] Published: January 2009) for those with a diagnosis of Borderline Personality Disorder who engage in frequent self-harm.

How is it beneficial?
DBT is helpful in learning skills to reduce self-harm and suicidal behaviours, manage intense emotions and tolerate a crisis without making the situation worse.