Is dialectical behavior therapy the right ‘fit’ for your patient?
4 steps can help you choose psychotherapies that are supported by the evidence
DBT also includes a strong focus on emotions and emotion regulation. Therefore, if difficulty managing emotions is among your patient’s primary problems, DBT may offer some benefit. DBT also includes structured interpersonal skills training that might be useful for patients who lack assertiveness.
Finally, if you have a patient with multiple diagnoses and severe problems—but not psychosis—the DBT approach to organizing and prioritizing treatment targets may be beneficial. Some multi-diagnosis patients may struggle with aspects of DBT (such as learning new skills), but DBT is set up to incorporate other empirically supported treatment protocols for co-occurring Axis I and II disorders.
Does DBT ‘fit’ your patient? DBT is very structured and involves direct discussions of maladaptive behaviors. If your patient prefers or would benefit from a structured approach, you might consider a referral for DBT.
DBT is an outpatient behavioral treatment that focuses on the here and now. DBT might not be the best fit if your patient:
- views his or her problems as resulting primarily from childhood experiences or relationships with parents
- would prefer insight-oriented therapy.
If, however, your patient would like a practical approach focused on problem-solving, DBT could be an effective choice.
DBT is based in part on a dialectical philosophy, and DBT therapists often seek to bring together or synthesize polarized thinking. If your patient struggles with “black or white” thinking, this dialectical philosophy might be helpful. On the other hand, DBT might not be the best fit if your patient is particularly rigid in thinking or seems to require cognitive therapy to address his or her thought patterns.
DBT is not the treatment of choice for all personality disorders. Most of the evidence examines its use for BPD, and few studies have looked at any other personality disorder. Also, keep in mind that being interpersonally “difficult” does not mean that a patient is “borderline” or needs DBT.
Step 4: Communicate reasons for referral to your patient
Finally, communicate to your patient the reasons you are referring him or her for DBT. Patients often walk into my office for DBT, confused about why they are there. If patients understand why they have been referred for DBT and how it may help them, they may be more likely to follow through and realize its benefits.
A sample explanation of referral that I offer to guide this communication (Box 2) includes 3 main points:
- my diagnosis or conceptualization of the patient’s clinical problems
- a brief description of DBT
- a rationale for why DBT would be a good fit, and what kinds of benefits the patient might receive.
Based on my initial assessment, you seem to meet criteria for a diagnosis of borderline personality disorder, or BPD. A diagnosis is a category for different symptoms or experiences. To receive a BPD diagnosis, a person has to have at least 5 of 9 symptoms, and you seem to have about 6 of them. From what you have said, the main problems you struggle with are roller-coaster emotions and moods, problems with relationships with other people, and self-harm.
A lot of people recover from BPD, and there’s no reason to think you will have these problems for the rest of your life. In fact, there is a very effective treatment for BPD. This treatment is called dialectical behavior therapy, or DBT. I think you’re a great candidate for DBT. Of course, there’s no guarantee that DBT is the ideal treatment for you, but several studies have shown that DBT helps people learn how to manage their emotions, reduce self-harm, and improve their functioning in life.
DBT includes a couple of different things: meeting once a week with a therapist on an individual basis, then meeting once a week with a group. In the group, you will learn how to manage your emotions, pay attention to the present moment, deal with other people, and tolerate being upset without getting into a crisis.
I know some people in town who provide DBT. Is this something you think you might be interested in? If so, what questions do you have?
Related Resources
- Chapman AL, Gratz KL. The borderline personality disorder survival guide: everything you need to know about living with BPD. Oakland, CA: New Harbinger Publications; 2007.
- National Education Alliance for Borderline Personality Disorder. Information for professionals, patients, and families. www.neabpd.org.
- Behavioral Tech, LLC, founded by Marsha Linehan, PhD. DBT training and resources, including a directory of DBT therapists. www.behavioraltech.org.
- Dialectical Behaviour Therapy Centre of Vancouver. www.dbtvancouver.com.
