“Dialectic” dilemmas are triggers that occur when a person is torn between 2 extreme feelings such as “I hate being around this person”, but “I can’t be alone so I can’t leave”.

Dialectical Behaviour Therapy (“DBT”) means applying both change strategies (problem solving) and acceptance strategies (validation and mindfulness) because BPD patients have the dialectic dilemma that they don’t want to change (i.e. want to be accepted as they are), but know they need to change.

DBT requires long-term exposure to treatment, so it is time consuming and is only provided by a small pool of specially-trained clinicians. Treatment usually takes 1 year with 4 sessions weekly and 2 years with 2 sessions weekly. The 2-year sessions typically include:

  • 1 day a week of group protocol-based psycho-education skills (mindfulness, interpersonal, distress tolerance & emotional regulation) plus
  • 1 day of individual therapy to help them use the skills effectively and understand their personal triggers & appropriate responses to those triggers.

DBT requires a team of clinicians to provide the therapy to prevent burnout from dealing with crisis after crisis.

DBT is hierarchical and treats the most serious issues first in this order:

  1. life-threatening (suicidal & parasuicidal), then
  2. therapy-interfering, then
  3. serious quality of life, then
  4. behavioural skills deficits, and finally
  5. less serious life problems and feelings such as desperation and incompleteness.

DBT teaches the patient to forget about what they want and radically accept what is so they can constructively change it in the future. The patient must radically accept:

  • the past and present,
  • one set of problems in order to focus on solving another set of problems, and
  • limitations on the future.

DBT is divided into four stages of treatment:

  1. In Stage 1, the person is often miserable and their behaviour is out of control. The goal is for the person to move from being out of control to achieving behavioural control.
  2. In Stage 2, the person may feel they are living a life of quiet desperation: their life-threatening behaviour is under control, but they continue to suffer. The goal is to help the person move from quiet desperation to full emotional experiencing.
  3. In Stage 3, the challenge is to learn to live: to define life goals, build self-respect and find peace and happiness so they can lead a life of ordinary happiness and unhappiness.
  4. For some people, Stage 4 is needed – to find a deeper meaning through a spiritual existence.

Some people have criticized DBT for its rigid rules leading to many people getting kicked-out, telling parents to use tough love to stop enabling the person with BPD, and telling people with BPD that they should avoid their parents because the parents are toxic and partly responsible for the onset of BPD.

DBT is the most common and most-studied therapy for BPD. Several studies show that DBT is effective in reducing self-directed violence, suicide, and psychiatric crisis interventions.