Dr. Abigail McNally is a private practice psychologist in Cambridge, Massachusetts, whose specialties include the treatment of borderline personality disorder. According to McNally, one of the most effective treatment options for the most severe forms of this disorder is Dialectical-Behavior Therapy (DBT).

DBT was developed as an offshoot of Cognitive Behavior Therapy (CBT), which is based on the idea that intense negative feelings can be changed through changing one’s thoughts and/or behaviors. In the context of borderline personality disorder, McNally reflects that CBT techniques alone proved of limited use due to: a) the severity of the affect regulatory symptoms in BPD, b)the difficulty forming a treatment alliance, c) difficulties prioritizing areas of foci amidst a sense of constant crisis, and d) therapist burn-out amidst chronic extreme symptoms.

Developed by Marsha Linehan, Ph.D., DBT addresses these drawbacks of the CBT model by adding supportive/empathic/containing structure to the treatment model as a whole. First, DBT maintains CBT’s focus on change-related coping strategies, while adding acceptance-based strategies rooted in the Eastern meditative philosophy of mindfulness. Second, DBT maintains a pointedly empathic stance towards the patient’s dysregulated or otherwise seemingly self-destructive behavior, by validating the ways maladaptive responses may still serve an important emotion regulatory or interpersonal function. The model identifies maladaptive yet understandable ways of coping with alternative, healthier strategies. Third, therapist and patient commit to a 6-month treatment frame in which a hierarchy of pathological behaviors is addressed in order from severe (e.g., suicidal behaviors) to less severe (e.g., social anxiety). This helps to prioritize the breadth of fluctuating severe symptoms and take most seriously those that are at the most serious end of the continuum of harm. Finally, unlike most other behavioral treatment models, formal DBT specifically includes therapist participation in a peer consultation team for guidance and support. Full model DBT includes a weekly DBT skills group and weekly individual therapy sessions. Group sessions focus on the development of the four core skill areas (emotion regulation, interpersonal effectiveness, mindfulness, and distress tolerance), while individual sessions focus on the individualized tailoring and application of skills in external life. Formal DBT also includes therapist extra-session availability for skills coaching in moments of crisis as well as the aforementioned therapist consultation group.

Since its inception, DBT has been broadly applied to a range of affect regulatory disorders such as post-traumatic stress disorder, eating disorders, and substance abuse.