Several concerns about this treatment model are related to the fact that BPD is a difficult disorder to treat, with a lengthy developmental history that is frequently slow to change. In addition, BPD is commonly comorbid with a range of Axis I and Axis II disorders, thus potentially increasing the complexity and length of treatment. Furthermore, individuals with BPD have disordered attachment, leading to difficulties with forming and ending relationships. To address these multiple complications, DBT is a staged therapy, designed to continue for more than 1 year in most cases to allow for the Stage 2 targets. The effects of premature termination of treatment have not been fully explored. The DBT approach is also highly structured and specific with regard to interventions, and this model does not fit all populations (Wagner, Rizvi, & Hamed, 2007).
Studies that have examined the efficacy of treatment have had limitations. For some studies, sample sizes were small and highly specific, thus limiting the generalizability of the results to standard clinical settings. In addition, the DBT groups were typically compared with treatment interventions that did not allow for the effects of motivated and enthusiastic clinicians, number of hours of treatment, counselor expertise, or supervision.
Finally, although thousands of treatment providers have been trained and are located all over the world, "there are not enough people trained," according to Linehan (Van Nuys, 2007). Thus, access to this specialized therapy continues to be somewhat limited.
Summary Chart: Dialectical Behavior Theory
Dialectical behavior therapy was developed to treat clients with BPD. It maintains that certain individuals who are exposed to invalidating environments during childhood in combination with biological factors react abnormally to emotional stimulation. Dialectical behavior therapy conceptualizes behavior broadly, to comprehensively address thinking, feeling, and behavior. Emphasis is placed on the function of behavior and the context in which behavior occurs. Its strength is its ability to explain the development of thought and experience over time.
Dialectical behavior therapy is a comprehensive treatment that merges cognitive-behavioral therapy with mindfulness-based practices of Buddhism. It balances the concept of learning behavioral change with the corresponding concept of learning acceptance. The DBT model emphasizes the identification of stimuli that trigger dysfunctional behaviors through previously learned associations and the outcomes that shape the development and maintenance of a behavior. 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. It is highly structured, particularly during the initial stage of treatment when the client is lacking behavioral control and consequently engaging in dysfunctional and life-threatening behaviors. The main components of DBT are emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness training. Clients receive three main modes of treatment: individual counseling, skills group, and phone coaching. This model aims to reduce self-injurious and suicidal behaviors, behaviors that interfere with the therapeutic process, and behaviors that diminish the client's quality of life.
Dialectical behavior therapy targets behaviors in a descending hierarchy. Prior to the initiation of counseling, a commitment for participation is secured from the client. Once treatment is initiated, the emphasis is on decreasing high-risk suicidal behaviors and moving from being out of control of one's behavior to being in control. The second stage of treatment targets helping clients move from being emotionally shut down to experiencing emotions fully by addressing any resistance that has the potential to interfere with the therapeutic process. The third stage of treatment works with clients on daily stressors and assists with solving behaviors that interfere with or reduces the quality of life. During this stage, the model also targets decreasing and dealing with PTSD responses. The final stage of counseling promotes moving from incompleteness to completeness through enhancing respect for self and promoting the acquisition of behavioral skills for coping with distress.
The DBT model proposes that successful counseling intervention meets five critical functions: (a) improve and preserve the client's incentive to change, (b) boost the client's capabilities, (c) ensure that the client's new capabilities are generalized to all relative environments, (d) enhance the counselor's motivation to treat clients while also enhancing the counselor's skills, and (e) structure the environment so that the treatment can take place.
Dialectical behavior therapy uses the primary strategies of cognitive-behavioral therapy. A number of supplementary and distinctive strategies are included in the treatment to augment the value of treatment. In line with dialectical ideology change, strategies are combined with acceptance strategies, including strategies to increase commitment to therapy, problem-solving strategies, validation strategies, and dialectical strategies.
Concerns about this treatment model are related to the fact that BPD is a difficult disorder to treat, with a lengthy developmental history that is frequently slow to change. In addition, BPD is commonly comorbid with a range of Axis I and Axis II disorders, thus potentially increasing the complexity and length of treatment. To address these multiple complications, DBT is a structured therapy designed to continue for more than 1 year in most cases to allow for the Stage 2 targets. This model does not fit all populations (Wagner et al., 2007).