Why was Dialectical Behavioural Therapy developed?

Development of DBTLinehan and her research team initially applied standard Cognitive Behavioural Therapy techniques when working with their suicidal client group. However, during treatment they observed numerous problems with its use. 
Three factors were particularly problematic and consistently influenced treatment outcomes:

1. Clients receiving CBT found the unrelenting focus on change invalidating of the difficulties they faced. As a result, clients often responded by withdrawing from treatment, by becoming angry, or by vacillating between the two. This resulted in a high drop out rate. And, obviously, if clients do not attend treatment, they cannot benefit from treatment.
2. Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy. For example, therapists might back off when trying to help a client to change if they responded with anger thus their helpful responses was (unconsciously) punished by the client.
3. The sheer volume and severity of problems presented by this particular client group made it impossible to use the standard CBT format. Individual therapists simply did not have time to both address the problems presented by clients – suicide attempts, urges to self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, etc, — AND have session time devoted to helping the client learn and apply more adaptive skills. 

In response, Linehan and her colleagues added other components to the standard CBT model addressing these specific difficulties and increasing its effectiveness.
 
Adding Validation and Dialectics to CBT. 
Acceptance-based interventions, frequently referred to as validation strategies, were added. Adding these communicated to the clients that they were both acceptable as they were and that their behaviours including those that were self-harming, made real sense in some way. The emphasis on acceptance did not exclude the emphasis on change. Clients must  also change if they want to build a life worth living. Thus ,treatment focuses on both acceptance and change. Dialectical strategies gave the therapist a means to balance acceptance and change in each session .They also serve to prevent client and therapist from becoming stuck with thoughts, feelings and behaviours that can occur when emotions run high in the therapy setting with those with BPD diagnosis. Dialectical strategies and a dialectical world view, with its emphasis on holism and synthesis, enable the therapist to blend acceptance and change in a manner that results in movement, speed, and flow in individual sessions and across the entire treatment.
Functions and Modes. Linehan (1993) hypothesizes that any comprehensive psychotherapy must meet five critical functions. The therapy must: a) enhance and maintain the client’s motivation to change; b) enhance the client’s capabilities; c) ensure that the client’s new capabilities are generalized to all relevant environments; d) enhance the therapist’s motivation to treat clients while also enhancing the therapist’s capabilities; and, e) structure the environment so that treatment can take place.
Standard outpatient DBT meets these functions by offering Individual therapy sessions, skills training groups, skills coaching and a therapist consultation group.
It is typically the individual therapist who maintains the client’s motivation for treatment, since the individual therapist is the most salient individual for the client.
Skills are acquired, strengthened, and generalized through the combination of skills groups, phone coaching (clients are instructed to call therapists for coaching prior to engaging in self harm), in vivo coaching, and homework assignments.
Therapists’ capabilities are enhanced and burnout prevented through weekly consultation team meetings. The consultation team helps the therapist stay balanced in his or her approach to the client, while supporting and cheerleading the therapist in applying effective interventions.
 
Finally, the environment can be structured in a variety of ways, say by the client and therapist meeting with family members to ensure that the client is not being reinforced for maladaptive behaviours or punished for effective behaviours in the home.
 
Stages and Targets.
 DBT also organizes treatment into stages and targets and, with very few exceptions, adheres strictly to the order in which problems are addressed. The organization of the treatment into stages and targets prevents DBT being a treatment that, week after week, addresses the crisis of the moment. Further, it has a logical progression that first addresses behaviours that could lead to the client’s death, then behaviours that could lead to premature termination of therapy, to behaviours that destroy the quality of life, to the need for alternative skills. In other words, the first goal is to insure the client stays alive, so that the second goal (staying in therapy), results in meeting the third goal (building a better quality of life), partly through the acquisition of new behaviours (skills). In short, we have just described the targets found in Stage I.

 In Stage II, DBT addresses the client’s inhibited emotional experiencing. It is thought that the client’s behaviour is now under control but the client is suffering “in silence”. The goal of Stage II is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated.

Stage III DBT focuses on problems in living, with the goal being that the client has a life of ordinary happiness and unhappiness.

 Linehan has posited a Stage IV specifically for those clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfilment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.

Adapted from the behavioural tech website.