B.F. Skinner Meets Buddha in DBT
By Sally Hansell, LCSW

The treatment of borderline personality disorder has taken lifesaving leaps in the past decade with the development of Dialectical Behavior Therapy, also known as DBT. DBT provides a radically different approach from the traditional psychodynamic treatments for borderline personality disorder, and group work is central to its approach.

Since Seattle psychologist Marsha Linehan published a landmark study in 1991 providing empirical data for the efficacy of the treatment, DBT skills training groups have proliferated across the country. These groups have a structured, manual-based format that teaches clients the basic life skills of regulating emotion, tolerating distress, and acting effectively in interpersonal relationships. The weekly skills training groups are part of a system of treatment, which also includes outpatient individual counseling with a primary therapist and telephone consultations in which clients are coached to apply the skills to cope with the challenges of living. Group members are expected to complete daily “diary cards,” tracking their emotional intensity levels and skills used.

Background of DBT
Underlying this skills-based approach is Dr. Linehan’s belief that borderline individuals are deficient in emotion management skills. According to her bio-social theory, borderline personality disorder results from a biologically based emotional vulnerability (high sensitivity, high reactivity, and a slow return to baseline) in combination with environmental factors that invalidate emotions over time and thwart the use of skills. This is a controversial departure from the psychoanalytic community’s view of borderlines as deficient in personality structure and personality functioning. In fact, Dr. Linehan advocates a name change for the much maligned borderline diagnosis, proposing instead the label of “emotion dysregulation disorder” and a reorganization of diagnostic criteria.

To reach the severe pain of these difficult-to-treat clients, DBT blends cognitive behavioral strategies with acceptance-based treatment that is rooted in meditation and Eastern spirituality. Dr. Linehan, a professor of psychology at the University of Washington, infuses DBT with the mindfulness skills from her training in Zen Buddhist monasteries in California and Germany.

DBT evolved from failed attempts to apply the standard cognitive-behavior therapy of the 1970s to chronically suicidal individuals. DBT places a much greater emphasis on acceptance and validation of clients with the recognition that the therapeutic relationship is at times the only thing that keeps these clients alive. The “dialectical” philosophy of DBT refers to the synthesis of opposites in therapy and in life. The fundamental dialectic of DBT lies in accepting clients as they are in each moment while also helping them to change “from a life in hell to a life worth living,” as Dr. Linehan writes.

Research on DBT 
The meteoric rise of DBT dates to the 1991 publication of a randomized clinical trial, conducted by Dr. Linehan and her colleagues, which showed positive outcomes for chronically suicidal women who met criteria for borderline personality disorder and received DBT. In comparison with the control condition, which was “treatment as usual in the community,” the DBT subjects had fewer incidences of parasuicide1, less medically severe parasuicides, and fewer inpatient psychiatric days.

Subsequent randomized clinical trials by Dr. Linehan and her colleagues, as well as replication trials by other researchers, have produced similar results supporting the efficacy of DBT. All research to date has focused on clients who demonstrated severe behavioral dyscontrol with suicidal behaviors and are in “Stage One” of three hierarchical treatment stages identified by Dr. Linehan. Despite this rewarding data, it would be premature to identify DBT as the treatment of choice for borderline individuals. “No data has been collected on psychodynamic treatment approaches. In the absence of this data, it’s hard to know,” said Kelly Koerner, PhD, when asked if DBT is more effective than psychodynamic treatment for this population. (Dr. Koerner is President of The Behavior Technology Transfer Group, Linehan’s training organization in Seattle, which develops and disseminates treatment to mental health centers, state hospitals, day treatment programs, forensics units, managed care companies, and other providers.) As for how many DBT groups might be underway today, she said it is impossible to know because, in addition to her firm’s services, DBT training is offered by other professionals and also in self-guided training forms. It appears that Dr. Linehan’s refining, testing, packaging, and marketing of the skills have caused DBT groups to proliferate.

DBT not only has evolved as a treatment for borderline personality disorder but also has been adapted for treating substance abuse in borderlines and for eating disorders. Current research is investigating DBT adapted for depressed elderly persons, for couples and families, and for suicidal adolescents. 

What does DBT teach?
The actual skills taught in DBT groups are ancient and familiar. For example, mindfulness skills, which are versions of Eastern spiritual training, include observing, describing, participating in the here and now, taking a non-judgmental stance, focusing on one thing in the moment, and being effective. Clients learn the differences between three primary states of mind: “emotion mind,” the “hot” state when emotions are in control; “reasonable mind,” the cool, logical part of the mind that plans things; and “wise mind,” which integrates the emotional and intellectual states and goes beyond them to include intuitive knowing. Ever validating, Dr. Linehan emphasizes that everybody has wise mind梚t is that part of each person that can experience truth and know something in a centered way. Mindfulness skills, which form the core of DBT, are taught for two sessions at the beginning of each of the three skills modules (interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills).

Interpersonal effectiveness skills include basic assertiveness training: how to set goals and priorities in relationships, guidelines for keeping a relationship, maintaining one’s self-respect, and a cognitive challenging of common myths about relationships (for example, “Saying no to a request is always a selfish thing to do” or “I don’t deserve to get what I want or need”). Clients are given “cheerleading statements” or positive self-affirmations to help battle their internalized myths and are encouraged to generate their own. One of the most colorful, created by my clients, is, “My ears ain’t garbage cans!”

Similarly, emotion regulation skills include myths about emotions, ways to describe emotions, guidelines for staying out of emotion mind, steps for increasing positive emotions, and using opposite emotions. Clients learn to do a chain analysis of problem behaviors. Distress tolerance skills include distraction, self-soothing, listing pros and cons, visual imagery, relaxation, prayer, breathing exercises and “half-smiling exercises” reminiscent of Buddha’s serene expression.

A clinical example
In my experience, DBT has been an essential and life-saving component of therapy in a day treatment setting with clients who are both seriously mentally ill and chronically suicidal. All the group members have strong features of borderline personality disorder, if not the actual diagnosis, in addition to Axis I diagnoses including schizophrenia, mood disorders, PTSD, and dissociative identity disorder. All are in the first of the three hierarchical stages of treatment, and the goals of this stage center on decreasing suicidal behaviors, decreasing therapy-interfering behaviors and quality-of-life interfering behaviors, and building behavioral skills.

I have co-led a weekly DBT group with this population for one year, with a typical group size after attrition of four or five members in each skills training module. The session lasts 110 minutes, with the first half devoted to reviewing diary cards and the second half to teaching new material. While we originally allotted eight weeks for each module as Dr. Linehan recommends, the modules have stretched sometimes to 12� weeks, perhaps because of the high level of group participation. I am unsure if the prolonged module times are due to our negligence as group leaders in limiting group process material, or whether we have just been too thorough in covering the diary cards and discussion points in the manual. We do allow group members to give supportive feedback based on the skills and often ask which skills might be helpful for a particular problem.

The following is a sample of a typical group interaction during a recent review of diary cards. I had informed the group that I was writing this article and solicited brief feedback about DBT.

Client A: “It’s been an emotional lifesaver for me. These skills have literally saved my life.” She volunteered that in the past week she made up her own scale for emotional intensity: “Going from zero to five wasn’t good enough. I went from one to 100 and 100-plus!” (In the previous DBT group, this borderline client had talked about wanting to cut herself in response to multiple stressors related to abandonment issues: her primary therapist had terminated with her the previous day to pursue other job opportunities; the program director was out of the office for two weeks following surgery; her work unit supervisor had just returned from his honeymoon; and another primary staff member was resigning. Two years ago, this client was cutting herself with knives from the kitchen at the day program, and two years of emotion management skills training and reinforcement have been central to her enormous progress.)

S.H.: validated Client A’s amazing, hard work in using the skills and the progress in behavior control she has shown since last week. Recognized client’s ability to cope with the additional tragic loss of her father’s girlfriend’s death in a motorcycle accident three days ago. Visually reviewed client’s diary card.

Client B: Echoed group leader’s validation of Client A and acknowledged Client A’s coming to the day program to connect with her support system.

S.H.: Identified coming to the day program as an “effectiveness” skill (doing what needs doing).

Client C: “DBT has given me steps to get back into a healthy lifestyle and to get control. If I didn’t have my DBT skills, I don’t know if I would have made it through last week.” He then listed skills used in the past week and elaborated on using pros and cons: “I started to quit taking my meds because it wasn’t doing me any good. I skipped one dose and then realized that I would get worse and lose my apartment.”

S.H.: Compared client’s cognitive process to “thinking through the drink,” a skill he probably learned in dual diagnosis groups for substance abuse recovery. Asked to see client’s diary cards.

Client C: “I tore my skills notebook into about 50 million pieces! I even tore the rings out of the plastic. I was frustrated over not being able to use the skills.”

S.H.: Voiced observation that this was better than “tearing up” his apartment as client did several months ago. Handed him some new diary cards.

Client C: Admitted he got tired of cleaning up after his destructive rages in the apartment.

Co-leader: Reminded Client C to take a non-judgmental view of self regarding his inability to use the skills at times.

Client C: Disclosed that he does not want to go back to dual diagnosis groups due to feeling angry at the leader and members in that group.

Co-leader: “This is a good opportunity to practice opposite action. I don’t mean to invalidate your anger, but maybe you could imagine empathy for that person instead of anger.”

Several group members who have participated in skills training for a year or more have asked wistfully, “When will I ever graduate from DBT?” Indeed, graduate DBT groups are available in some locations for clients who have assimilated the basic skills and achieved some behavioral control with a cessation of self-harming behaviors. Meggan Morehead, EdD, Clinical Assistant Professor of Psychology at the University of North Carolina-Chapel Hill and Clinical Associate at Duke University Medical Center, has co-led a graduate DBT group for almost four years. Her policy is to accept members in the process group if they have been free of self-harm behavior for six months. If the self-harm recurs, the members talk about it in group to get help for their relapse. Dr. Moorhead’s 90-minute groups consist of an opening five minutes mindfulness practice, a 10� minute teaching session, a check-in, and for the remaining time a process group in which members assume the leadership role. The teaching responsibilities are shared by everyone, including the group leaders, in alphabetical order, and the skills are reviewed one by one. 

“The leaders have taught behavior principles, behavioral analysis, solution analysis, and anything else new in DBT that has come down the pike,” Dr. Moorhead wrote in an e-mail. “I have observed that (the goal of) skills class in the first year is to learn skills and to apply them to life-threatening patterns. In stage two, the skills are used to tolerate the treatment for those individuals who have trauma and PTSD,” she wrote, noting that stage two work is done in individual therapy. “In the third stage we use skills to make a life worth living.” And this simple phrase�”a life worth living”梚s immeasurable by any research study.

1 Norman Kreitman introduced the term “parasuicide” in 1977 “as a label for (1) nonfatal, intentional self-injurious behavior resulting in actual tissue damage, illness, or risk of death; or (2) any ingestion of drugs or other substances not prescribed or in excess of prescription with clear intent to cause bodily harm or death,” Dr. Linehan writes in her book Cognitive-Behavioral Treatment of Borderline Personality Disorder. She prefers the term “parasuicide” to “suicide gestures” or “manipulative suicide attempts,” because it is less perjorative and does not involve a “motivational hypothesis” such as an attempt to communicate or manipulate.

Kreitman, N. (1977). Parasuicide. Chichester, England: Wiley.

Linehan, Marsha M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

Linehan, Marsha M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.

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, 1060-1064.