Dialectical behavior therapy is a comprehensive treatment that integrates cognitive- behavioral therapy with acceptance-based "Eastern psychological and spiritual practices" (Linehan, 1993b, p. 6). It emphasizes the importance of the psychotherapeutic relationship, validation of the client, the impact of having been raised in an invalidating environment, and confrontation of resistance. Dialectical behavior therapy was developed from an approach that views BPD as a "combination of motivation problems and capability deficits" (Linehan, 1993b, p. 6). It is highly structured, particularly during the initial stage of treatment when the individual is lacking behavioral control and consequently engaging in dysfunctional and life-threatening behaviors. The main components of DBT are affect regulation, distress tolerance, improvement in interpersonal relationships, and mindfulness training. Ultimately, clients learn to restrain dysfunctional emotion-driven behaviors and to initiate behaviors that are free of current mood and contribute to the ability to meet long-term goals. Counselors of DBT do not approach helping clients through insightful discussions, although insight can be helpful at times. Learning new behaviors is critical in DBT and is a focus in every session, skills group, or phone call.
Dialectical behavior therapy's biosocial theory of BPD views the disorder as primarily one of pervasive emotional dysregulation, a result of both highly emotional vulnerability and deficits in the ability to regulate emotions. Biosocial theory helps a person to understand not only the etiology of BPD and its problem areas but also the maintenance of the disorder. Linehan (1993b) viewed dysfunctional behaviors in individuals with BPD either as an attempt by the individual to regulate intense affect or as an outcome of emotional dysregulation. Thus, for example, clients may deliberately harm themselves as a means to distract attention away from emotionally salient stimuli and thereby reduce anguish, or they may be lashing out when feeling overwhelmed. The DBT theory views emotions as involving a full system response and not merely the individual's phenomenological experience of the emotions. Linehan's model also assumes that emotions are prompted by events and function to organize and motivate action. Emotions inform individuals about the personal significance of situations (McMain et al., 2001). The accurate identification of an emotional response is critical to the regulation of emotions.
The DBT model assumes that individuals with BPD lack key interpersonal and selfregulation skills and that personal and environmental factors may block the use of appropriate responses to stressors or reinforce maladaptive responses. Thus, DBT is designed to facilitate the learning of new skills and generalization of the new skills across contexts.
The source of emotion dysregulation in individuals with BPD is viewed as resulting from the perfect storm of biological anomalies combined with an invalidating environment (Linehan, 1993a). These biological irregularities in BPD are believed to be caused by biological or genetic factors or childhood events. These irregularities are thought to result in emotional vulnerability offering insight into affective instability, impulsive, selfdestructive, and aggressive behaviors characteristic of BPD (Siever & Davis, 1991). Linehan (1993a) believed that an invalidating environment communicates to individuals that their interpretations and perceptions of their experiences are fundamentally wrong. The person therefore does not learn to accurately label internal experience or to regulate emotional arousal. In addition, these individuals do not learn to trust their own thoughts and feelings as accurate and reasonable responses to internal and environmental events. Rather, they are taught to invalidate their own perceptions and to scan the environment for cures about how to react. The invalidating environment also conveys to individuals that their experiences are due to unacceptable and undesirable character traits. For example, "a child is 'bad' for feeling angry, 'lazy' for not getting over loss quickly, or 'weak' for feeling afraid" (McMain et al., 2001, p. 186). Because the child is routinely ignored or punished for his or her emotional responses, appropriate coping mechanisms for dealing with these emotions are not learned. Additionally, because the system within the environment commonly responds to hysterical displays of emotions, the extreme behaviors are inadvertently reinforced, teaching that extreme displays are needed to gamer a response from the environment. This combination of ignoring or punishing emotional responses in combination with reinforcing the extreme emotional states results in teaching the child to shift between emotional inhibition and extreme emotional states.