Linehan observed "burn-out" in therapists after coping with non-motivated patients who repudiated co-operation in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments and therefore required a climate of unconditional acceptance (not Carl Rogers’ positive humanist approach, but Thich Nhat Hanh’s metaphysically neutral one) in which to develop a successful therapeutic alliance. Her second insight involved the need for a commensurate commitment from patients, who needed to be willing to accept their dire level of emotional dysfunction.
DBT strives to have the patient view the therapist as an ally rather than an adversary, in the treatment of psychological issues. Accordingly, in DBT the therapist aims to accept and validate the client’s feelings at any given time while nonetheless informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives.
Linehan and others combined a commitment to the core conditions of acceptance and change through the Hegelian principle of dialectical progress (in which thesis + antithesis → synthesis) and assembled an array of skills for emotional self-regulation drawn from Western psychological traditions (e.g., cognitive behavioral therapy and an interpersonal variant, “assertiveness training”) and Eastern meditative traditions (e.g., Buddhist mindfulness meditation). Arguably her most significant contribution was to alter the adversarial nature of the therapist/client relationship in favor of an alliance based on intersubjective tough love.
All DBT can be said to involve two components:
- An individual component in which the therapist and patient discuss issues that come up during the week, recorded on diary cards, and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority. Second in priority are behaviors which while not directly harmful to self or others, interfere with the course of treatment. These behaviors are known as therapy-interfering behaviors. Third in priority are quality of life issues and working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed.
- A group component in which the group ordinarily meets once weekly for two to two-and-a-half hours and learns to use specific skills that are broken down into four modules: core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills.
Neither component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context.
- Certain aspects of DBT are subject to debate, including the rule that states, "Any individual who misses four consecutive DBT meetings can no longer work with their preassigned DBT therapist, no matter how long they have been working together." Although this rule is intended to encourage participation, Peer Counselors and Disability Advocates like Raquel Santiago, a certified peer counselor and first responder in San Francisco, argue that this rule tends to penalize patients unfairly, since even hospitalizations for medical purposes are not exempt.
- Additionally, learning and remembering the counter-intuitive acronyms used to label the modules can pose a challenge to people who suffer from cognitive processing delays caused by either medication, the symptoms of their diagnosis, or other organic functioning issues. (no citation needed patients with memory problems in relation to the above facets is common knowledge in the medical community)