Harmony DBT in St. Louis, Missouri, offers nine free audio tracks  for people to learn about Dialectical Behavior Therapy (DBT) . DBT is a mainstay in psychotherapy treatment for people with certain personality and mood disorders. It was developed by Marsha M. Linehan  for use in treating Borderline Personality Disorder (BPD)  patients.
DBT Applies to More Than BPD
Given the methods used in DBT and the similarities between BPD and certain other mental health disorders, DBT has broader applicability than simply for BPD patients. It also applies to a range of other personality and mood disorders, including patients with severe suicidal behaviors and bipolar disorders. In particular, patients with other DSM-IV Axis II Cluster B personality disorders including Narcissistic Personality Disorder , Antisocial Personality Disorder , and Histrionic Personality Disorder  are also likely to benefit from DBT as they also suffer from overly emotional behaviors, unrealistic perceptions of others and themselves, and a willingness to attack others and/or portray themselves as victims. DBT is designed to help address all of these behavioral and perception problems by helping patients learn to more objectively see situations, understand intent and avoid paranoia, and learn more effective coping mechanisms.
DBT is Cognitive Behavioral Therapy Adapted for BPD Patients
Marsha Linehan’s early writings on DBT and Cognitive Behavioral Therapy (CBT) for victims of BPD were first published in 1993 as a pair of books. The books were intended both for therapists and patients.
The guidelines and exercises in her books may seem overly simplistic, sometimes appearing as if they were designed for children. This is an accurate perception. Borderlines often had a very dysfunctional childhood, and their “emotional age” might be the equivalent of that of a five year old child. They often had their social and emotional development stunted around that age because of some factors that made them perceive the world as full of threats and insecurity and they found the way to manage this was to behave in an extreme, reactive, manipulative, and controlling fashion.
In general, it is unclear whether the environmental or genetic basis for BPD is more significant. It appears to vary from case to case.
The causes for the development of BPD often involve child abuse or neglect, often by one or two mentally ill parents who may have BPD or similar mental health problems and may themselves have been child abuse victims. Like child abuse, BPD tends to run in families and pass from one generation to the next.
Recent research indicates there are apparently neurological and genetic factors in many BPD cases, too. A recent study shows that BPD may be linked to certain genetic patterns on chromosome 9 . Another study shows that brain scans done on BPD patients  have significantly different appearances than for those who do not have BPD. Like genetic disorders such as cystic fibrosis, BPD tends to run in families and pass from one generation to the next.
BPD from the DBT Perspective
Linehan describes BPD in an article from 1997:
Dialectical Behavior Therapy: Foundations
DBT is based on a model suggesting that both the cause and the maintenance of BPD is rooted in biological disorder combined with environmental disorder. The fundamental biological disorder is in the emotion regulation system and may be due to genetics, intrauterine factors before birth, traumatic events in early development that permanently affect the brain, or some combination of these factors. The environmental disorder is any set of circumstances that pervasively punish, traumatize, or neglect this emotional vulnerability specifically, or the individual’s emotional self generally, termed the invalidating environment. The model hypothesizes that BPD results from a transaction over time that can follow several different pathways, with the initial degree of disorder more on the biological side in some cases and more on the environmental side in others. The main point is that the final result, BPD, is due to a transaction where both the individual and the environment co-create each other over time with the individual becoming progressively more emotionally unregulated and the environment becoming progressively more invalidating.
Emotional difficulties in BPD individuals consists of two factors, emotional vulnerability plus deficits in skills needed to regulate emotions. The components of emotion vulnerability are sensitivity to emotional stimuli, emotional intensity, and slow return to emotional baseline. “High sensitivity” refers to the tendency to pick up emotional cues, especially negative cues, react quickly, and have a low threshold for emotional reaction. In other words, it does not take much to provoke an emotional reaction. “Emotional intensity” refers to extreme reactions to emotional stimuli, which frequently disrupt cognitive processing and the ability to self soothe. “Slow return to baseline” refers to reactions being long lasting, which in turn leads to narrowing of attention towards mood congruent aspects of the environment, biased memory, and biased interpretations, all of which contribute to maintaining the original mood state and a heightened state of arousal.
An important feature of DBT is the assumption that it is the emotional regulation system itself that is disordered, not only specific emotions of fear, anger, or shame. Thus, BPD individuals may also experience intense and unregulated positive emotions such as love and interest. All problematic behaviors of BPD individuals are seen as related to re-regulating out of control emotions or as natural outcomes of unregulated emotions.
Reviews of Linehan’s DBT Books
Both of Linehan’s early books (as well as newer ones) have been very well reviewed by professionals familiar with treating BPD.
(professional review quoted on Amazon.com)
“…If you decide to expand your knowledge of this interesting linkage [between BPD and family violence], this is the only book you will need to read. Marsha Linehan’s Cognitive-Behavioral Treatment of Borderline Personality Disorder is the very best work done on the topic to date. It is extraordinarily well written. The examples are well chosen. The documentation is superb…The last section of the book describes specific therapeutic strategies for structuring the treatment plan. Nothing is forgotten, nor left undone in these sections. It is the most exacting and well thought out treatment plan I have ever seen written for any disorder. From this perspective, it is a useful book to read for guidance or insight on treating any mental health disorder…I have tried to find shortcomings with this book. I can find none. It is one of the best pieces of clinical work ever written. No matter what your clinical or research focus of interest, you will gain immensely from reading Cognitive-Behavioral Treatment of Borderline Personality Disorder.” —Journal of Family Violence
BPD patients who have undertaken DBT treatment using Linehan’s books have also been very positive:
(one of many positive BPD patient reviews from Amazon.com)
In twelve-step groups they usually say something like “take what you need and leave the rest.” I would suggest that non-borderline clients and the practitioners who help them follow that advice with this book. There is no need to erase us from the title of this book so that non-BPDs will feel less shame buying or using it. And there is no need to judge the exercises and handouts as overly simplistic. They are what they are. They were designed to help us (borderlines).
If you are not borderline, and do not have experience working with borderlines, you really don’t know what we need. Marsha Linehan does. I’m not claiming that every example or every exercise in the book works for every borderline, but M.L. does not claim that either!
Many borderlines (including myself) were traumatized in early childhood and failed to learn basic skills at that age. Therefore, exercises that to the non-BPD sufferer seem designed for children, were actually designed for people who never had the chance to experience a normal childhood and learn the social skills that others learned as children.
I do agree with the reviewers who say that much of DBT is helpful for people with other diagnoses, and even people who are not mentall ill, but this manual is for US, and does not need to be changed. Those who are not a part of the target audience should use what they can, and leave the rest – without judgement.
Those practitioners who see the applicability of DBT to non-borderline patients should take the time to figure out what works and write new books with new therapies, based on DBT. That is what Marsha Linehan did. She took CBT as a framework and developed DBT for a specific population – people who suffer from Borderline Personality Disorder.
For me, the DBT program that I attend, which uses this book as a handbook, has been invaluable. I needed this training. When I started DBT 5 months ago, while I did not feel suicidal, I felt that my self-destructive behaviors were eventually going to lead to my premature death. I had a term for this. I called myself “terminally incompetent” even though I have a high IQ, an advanced degree, etc. I just meant that eventually, my inability to simply get along in the world was going to kill me. I have felt this way all of my life, and I’ve been describing myself using that term for years, even though I had 10 years of therapy before this program. Now I still have ups and downs, and I still need many more years of therapy, but I know I’m going to make it.
Thank you, Marsha Linehan, and thank you Transitional Day Treatment Program at St. Luke’s-Roosevelt Hospital (NYC).
There are dozens more professional and patient reviews of these books available via these links:
If you’ve got a loved one with BPD or are raising children with a spouse or ex-spouse with BPD, learning about DBT can provide you with tools to help manage their borderline thought processes even if they are not willing to undergo DBT therapy themselves.
DBT Applied to Disorders Other than BPD
If an important person in your life doesn’t have BPD but instead has another disorder (depression, bipolar disorder, substance abuse, eating disorders, etc.) that might be helped by DBT, you and/or a therapist may want to consult Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings . This is a book written in 2007 that presents modifications to “standard DBT” to tune it for mental health patients with problems other than Borderline Personality Disorder. The included worksheets and forms can also be downloaded from the publisher’s website by clicking here .
One of the many professional reviews of this book:
“DBT is one of the most important advances in clinical practice in the last two decades. What began as a specific intervention for borderline personality disorder is in the process of evolving into a major approach that can be applied to a wide range of patients across multiple settings. This book impressively demonstrates this evolution, providing a resource that will be of value to therapists and students alike. I highly recommend it.”–Steven D. Hollon, PhD, Department of Psychology, Vanderbilt University
Other Recommended DBT Books
Further Listening and Reading
DBT In A Nutshell