By A.J. Mahari © 2005-2007

What is the difference between Dialectical Behavior Therapy and "regular" therapy?

Since I have not been trained in DBT but have only been exposed to it through reading and discussion with colleagues, my response to this question must be taken as the personal impression of an outsider to the technique. To make the question even more difficult to address, you are asking me to compare DBT to "regular" therapy, whatever that is! I expect that twenty patients would describe their experiences in therapy in as many different ways. So here's my best shot at an answer.

DBT appears to address most directly the fragmentation of experience that is the central theme of Lost in the Mirror. It places the experience of the moment in the context of the whole of experience. It therefore sets up forces in therapy that directly oppose the tendency toward splitting(black and white thinking). One of the main areas of focus is the tendency of the person with BPD to overvalue one's own ideas and stubbornly resist change, on the one hand, and to condemn oneself on the other hand. DBT is directed at achieving balance between such mutually exclusive options and learning to accept and value oneself in the present while still being open to making changes that will make life more fulfilling. DBT is simultaneously validating and challenging.

"Regular" therapy might be psychoanalytic psychotherapy, interpersonal therapy, behavior therapy, cognitive therapy, expressive therapy, or any of an infinite possibility of blends of these approaches. Whatever the technique, however, when therapy is done well, it validates the individual and his or her feelings in the present and encourages change when current responses are not effective in bringing a situation to a satisfying conclusion. The fundamental goals of all therapies are therefore the same. DBT has described them elegantly and in direct relationship with the black and white thinking that is fundamental to the world of BPD. Mutual respect between patient and therapist is the cornerstone.

Beyond the basic principles, however, DBT has structural requirements that further define it. It includes both individual and group components of treatment, the latter focussed on developing perceptual and problem solving skills, interpersonal skills, emotional regulation skills, and the capacity to tolerate stress and pain when necessary to survive and to achieve longer term objectives. It also includes a component of real world intervention, a broad availability of the therapist to coach patients by telephone through solving problems as they are developing. This is unique in that it goes beyond the usual availability for "emergencies" that most therapists provide.

DBT is therefore very labor intensive, given its three required components, and relatively expensive to provide. It is difficult for me to imagine a single therapist providing all three components unerringly to more than a few patients and maintaining his or her boundaries and sanity. Rather I imagine it as a team approach, provided in a clinic setting rather than a private office. I imagine the coaching function in particular to be shared among a team of therapists. The clinic setting also allows for peer support among therapists that is invaluable for anyone undertaking such a demanding task.

© Dr. Richard Moskovitz

Does DBT work better?