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Dialectical Behavioral Therapy


Overview of DBT

Dialectical behavioral therapy, or DBT, is a subset of cognitive-behavior therapy (CBT) that was developed in the late 1970's and early 1980's by psychologist Marsha Linehan at the University of Washington in Seattle specifically to treat borderline personality disorder (BPD). It has since been adapted to supplement treatment of other disorders involving emotional dysregulation as well, including treatment-resistant depression, eating disorders, and substance abuse, all of which often co-occur with BPD. DBT's goal is help increase adaptive skills and decrease behaviors that have come to cause suffering. Linehan has stated that the ultimate goal of DBT is to create "a life worth living." Dr. Linehan went public with her own struggle with borderline personality disorder in 2011.


Principles of DBT

The fundamental principle of DBT is learning to accept the reality your surroundings and the situations you find yourself in, and dealing with them in a constructive and benign manner. DBT requires its participants to be as honest as possible when addressing the thoughts, feelings, emotions, and behaviors that cause them distress and perpetuate actions that lead to self-harm and harm of others.


Mindfulness

Mindfulness involves being focused on the moment, with special attention given to thoughts, feelings, emotions, sounds, smells, and surroundings.
In his book Don't Let Emotions Run Your Life, Scott E. Spradlin lists the following attributes he associates with mindfulness:

  • Becoming more aware
  • Becoming more intentional
  • Becoming more participatory in your own life and experiences
  • Becoming more present and alive in each moment you live

Marsha Linehan classifies the skills of mindfulness as they relate to DBT as "What" skills and "How" skills.The "What" skills of mindfulness include the ability to observe, describe, and participate in your thoughts, feelings, emotions, environment, and experiences with a high level of awareness and in a manner that is non-judgmental. Rather than react to what you are thinking, feeling, and experiencing, being mindful requires its practitioners to pay close attention to what is happening in the moment without trying to manipulate anything, instead allowing thoughts and feelings to come and go unfettered. Instead of reacting to the moment or allowing oneself to become distracted, the mindful observer takes mental notes of what he or she is experiencing.

The "How" skills of mindfulness asks the participant to see things as they really are, without using judgmental terminology, such as "should," "must," "never," or "always." Instead of thinking of emotions or feelings as either good or bad, simply notice them as they occur without imposing value or judgment upon them. When engaging in mindfulness exercises limit yourself to a single activity and devote the entirety of your attention to that activity. Don't let distractions, be they internal or external, become barriers to what is happening in the here and now. It is imperative that the participant focuses solely on the present without drifting into thoughts about the past or concerns about what will happen in the future, even the immediate future.


Radical Acceptance

Another key component to DBT developed by Linehan is radical acceptance, which involves being completely honest with yourself about the reality of your life and the world and accepting that there are things you cannot change, regardless of the effort you exert attempting to do so. Radical acceptance does not require its practitioners to embrace reality; it simply asks us to acknowledge reality without fighting or judging it.


Emotional Regulation

There are two types of emotions: primary emotions and secondary emotions. Primary emotions are immediate physiological responses that are biologically hardwired, present in nearly all people and necessary for survival and healthy human functioning.
The nine primary emotions generally recognized by researchers include:
  • Joy
  • Love
  • Interest or Curiosity
  • Sorrow
  • Surprise
  • Fear
  • Disgust
  • Guilt
  • Anger

Secondary emotions are learned responses, called secondary emotions because they follow primary emotions and are often reactions to primary emotions. These emotions can be learned by observing how those around you-"particularly family members-"react to situations and other people, as well as how they react you as a child. Society has a significant influence on secondary emotions, with cultural norms often determining whether certain emotions and behaviors are considered acceptable or inappropriate.

Secondary emotions generally interfere with a person's ability to adapt to his or her circumstances, by judging how people feel things are supposed to be rather than helping them successfully navigate through the life and the world as they actually are. Emotional regulation teaches people to recognize their emotions as they occur, better understand why they are feeling those emotions, and interpret them in ways that lessen their vulnerability to being overcome by negative secondary emotions.


Distress Tolerance

Dialectical behavioral therapy teaches its students how to deal with their pain in a manner that focuses on acceptance and habituation. Accepting your pain doesn't mean you find pleasure in it or view it in a positive light. Rather, acceptance of pain involves examining your circumstances as objectively as possible, free of judgment, and learning to endure those things that are beyond your control (e.g., the physical suffering that accompanies an injury or the mental anguish felt when a loved one dies). There are four components to distress tolerance as outlined by Marsha Linehan. Those four components are as follows:
  1. Distraction: This exercise asks the person to find ways to distract him from whatever crisis he finds himself in. The means of distraction suggested are referred to as "wise mind ACCEPTS," an acronym for the seven distracting skills someone in crisis can use to get through a difficult situation. These include activities (doing things you enjoy that help you take your mind off whatever is causing you stress), contributing (doing volunteer work or helping out a friend), comparisons (comparing what you do to cope with stressful situations to what other people do or how you cope today to how you coped in years' past), emotions (immerse yourself in books, poetry, music, films, or television shows that trigger strong emotions), pushing away (cutting yourself off from the situation at hand by mentally blocking it out), thoughts (finding mentally-stimulating activities to do, such as crossword puzzles, playing video games, writing poetry, or solving mathematical equations), and sensations (finding means to elicit strong physical reactions, such as holding an ice cube for a minute or taking a long, cold shower; this is similar to self-harm but without the harmful effects).

  2. Self-Soothing: Self-soothing involves finding healthy means to comfort oneself involving any one of the five senses: touch, taste, smell, sight, and sound. This might involve taking a warm bath (touch), eating a tasty treat (taste), walking in a flower garden (smell), watching the sun set in the evening (sight), or listening to classical music (sound).

  3. Improving the Moment: Unlike most of the tools DBT teaches, "Improving the Moment" does not necessarily ask the participant to remain in the moment. Instead, when a moment of distress occurs, imagine a scenario where the situation is worked through successfully or one that is relaxing or enjoyable as a means to get your mind out of the negativity of the moment. Finding meaning to the crisis you're experiencing, prayer, and employing relaxation techniques are also recommended as ways to improve the moment. One of the most useful techniques is to completely immerse yourself in the moment, focusing on nothing else but what is causing you distress. While this may seem counter-intuitive, those who have practiced ITM have found it to be among the best exercises to help deal with stressful situations. Another technique is called "vacation," where a person who is in the middle of a crisis or simply having a bad day steps away from his or her troubles and does something to unwind, such as running an errand, engaging in a hobby, watching television, or meditating. The last ITM exercise is called "encouragement," where the person makes unambiguous-" and truthful-" affirmations to himself in a moment of crisis.

  4. Focusing on the Pros and Cons: An exercise best practiced when emotions are not at the breaking point, Pros and Cons requires the person to write a list of the advantages and disadvantages to tolerating distress and a list of the advantages and disadvantages to not tolerating distress. Looking at a situation from a thoughtful and analytical perspective rather than an emotionally-heated one can help to lead to a successful resolution.



Interpersonal Effectiveness

Interpersonal effectiveness involves teaching individuals how to communicate their needs to others, voice opinions that may be counter to those whose approval they might otherwise seek, and effectively realize goals they have long suppressed due to insecurity and fear.


DBT treatment

DBT treatment usually involves at least one weekly hour-long individual session and one weekly 2 to 2.5 hour-long group session, each headed by a DBT clinician. There may be additional weekly skills-training sessions with groups and one-on-one as well. Workbooks are used during and outside sessions. Psychotropic medication may be necessary to supplement a client's therapy, though DBT is generally the primary means of treating people with patterns of emotional dysregulation. Treatment generally lasts six months to a year, depending on the severity of the symptoms, frequency of sessions, and rapidity of progress.


Books that address skills associated with DBT include:

  • The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance by Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley
  • Doing Dialectical Behavior Therapy: A Practical Guide (Guides to Individualized Evidence-Based Treatment) by Kelly Koerner PhD and Marsha M. Linehan PhD
  • The Expanded Dialectical Behavior Therapy Skills Training Manual: Practical DBT for Self-Help, and Individual & Group Treatment Settings by Lane Pederson and Cortney Sidwell Pederson
  • The Dialectical Behavior Therapy Skills Workbook for Anxiety: Breaking Free from Worry, Panic, PTSD, and Other Anxiety Symptoms by Alexander L. Chapman PhD RPsych, Kim L. Gratz PhD, Matthew Tull PhD, and Terence Keane PhD
  • Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control (New Harbinger Self-Help Workbook) by Scott E. Spradlin
  • Don't Let Your Emotions Run Your Life for Teens: Dialectical Behavior Therapy Skills for Helping You Manage Mood Swings, Control Angry Outbursts, and Get Along with Others by Sheri Van Dijk MSW
  • Mind Over Mood: Change How You Feel by Changing the Way You Think by Dennis Greenberger and Christine Padesky
  • Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan
  • Out-of-Control: A Dialectical Behavior Therapy (DBT) - Cognitive-Behavioral Therapy (CBT) Workbook for Getting Control of Our Emotions and Emotion-Driven Behavior by Melanie Gordon Sheets PhD
  • Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings by Linda A. Dimeff Phd, Kelly Koerner PhD, and Marsha M. Linehan PhD ABPP
  • The High-Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, and Validation by Alan Fruzzetti PhD and Marsha Linehan PhD
  • The Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder: Using DBT to Regain Control of Your Emotions and Your Life (New Harbinger Self-Help Workbook) by Sheri Van Dijk MSW and Zindel V. Segal PhD


WORKS CITED:
  1. "An Overview of Dialectical Behavior Therapy." PsychCentral. 06 July 2012. Web. 29 January 2013.
  2. "Dialectical Behavior Therapy in the Treatment of Borderline Personality Disorder." PsychCentral. 06 July 2012. Web. 29 January 2013.
  3. Rivzi, Shireen. "Dialectical Behavior Therapy Fact Sheet." 29 August 2011. Web. 04 February 2013.


 

 
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