Dr. Linehan developed DBT based on her failed attempts to treat patients with severe dysregulation, including chronic self-injury and suicidality. When she and her research team applied standard CBT, they encountered numerous problems with its use. Three were particularly troublesome:
- Clients receiving CBT found the unrelenting focus on change inherent to CBT to be invalidating. Clients responded by withdrawing from treatment, becoming angry, or vacillating between the two. This resulted in a high drop-out rate. If clients do not attend treatment, they cannot benefit from treatment.
- Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy. For example, the research team noticed through its review of taped sessions that therapists would “back off” pushing for change of behavior when the client’s response was one of anger, emotional withdrawal, shame, or threats of self-harm. Similarly, clients would reward the therapist with interpersonal warmth or engagement if the therapist allowed them to change the topic of the session from one they did not want to discuss to one they did want to discuss.
- The sheer volume and severity of problems presented by clients 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, self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, and more) and have session time devoted to helping the client learn and apply the skills.
In response to these problems with standard CBT, Linehan made significant modifications to standard CBT, including adding acceptance and validation strategies to the change-based strategies of CBT, adding skills training as a separate component that occurs concurrent with individual therapy, and adding the DBT therapist consultation team.