Dialectical Behavior Therapy (DBT)

The overarching goal of DBT is to help individuals build a life they find worth living by developing the skills to manage emotions effectively, interact with others beneficially and authentically, and create an environment around them that is validating and accepting. Some would argue this is a primary goal of most therapeutic interactions.

DBT Origins

Marsha Linehan started as a researcher in the 1970s studying suicidal behaviors and later shifted to focusing on Borderline Personality Disorder. DBT was developed primarily by utilizing clinical experience and trial and error. As a method, it is rooted in behaviorism and gradually integrated dialectics as it became evident that behaviorism alone was insufficient for effective treatment.

What Exactly is ‘Dialectical’?

The foundation of DBT is dialectics, or the idea that opposites can coexist. To do this, one must learn that they can accept situations as they currently are, yet still, work on making an effort to improve anything they do not like about the situation. Think of dialectic as the balance of opposing forces in all things.

The idea of practicing acceptance while also actively working to promote growth and change may seem counterintuitive. After all, how many times have you heard about the importance of discomfort in eliciting change? By accepting things as they are, however, the changes come from a place of self-love rather than self-loathing and are more likely to be maintained long-term.

Think about yo-yo dieting as an analogy. An individual decides they hate themselves and engages in excessive workouts and restrictive eating, only to get lean, still hate themselves, but now also hate their lives. Positive mental health, like physical health, first comes from accepting who you are and loving yourself so much that you are willing to make lifestyle changes and adopt new maintainable habits, not extreme ones.

DBT Foundations

DBT is a combination of cognitive behavioral principles mixed with mindfulness practices and living. It focuses on teaching individuals skills to cope with heightened emotions effectively to minimize the chance that the individual will engage in negative, self-destructive behaviors when emotions are high.

Mindfulness is the practice of being in the moment rather than worrying about the future or past. It allows the individual to be aware of what is happening both internally and externally with a focus on remaining non-judgmental about anything that is occurring. The goal is to observe and be aware.

DBT does not consist of just individual treatment but also has a group therapy component. Learning the skills taught in DBT can be helpful regardless, but DBT is most effective when therapy is practiced in the same manner as established by the researchers. However, in cases where this is not manageable, any change in programming should make sure to include the essential tasks.

DBT seeks to:

• Enhance the individual’s capabilities
• Generalize them to their daily lives
• Improve motivations to change and
• Decrease dysfunctional behaviors, and structure the environment

Additionally, DBT is set up in a way to diminish the likelihood of clinician burnout when working with more problematic or stressful clients.

DBT techniques

Mindfulness and acceptance are at the foundations of DBT, however, there are four primary skills emphasized in the practice of DBT.

• Distress Tolerance – Often a significant problem of an individual’s in-the-moment difficulties lies in the fact that they are focused on thoughts that don’t help improve the situation, instead, they enhance it. Thoughts like ‘that’s not fair, ‘I’ll never get over this, and ‘this always happens to me serve only to enhance heightened emotions in a more distressing way. Learning to accept the situation as it is and stay out of the negative judgmental zone of thinking, helps individuals tolerate stressful situations. Only then are they able to solve the problem at hand should it need solving. Part of distress tolerance is learning the skills you can use at the moment to manage stress. Finding self-soothing techniques is key to managing those heightened in-the-moment emotions until the thinking brain can take control back. Every individual is different and no single technique can be used for everyone as a definite technique. Plan to have a backup plan or two. If going for a walk or run is your plan and there’s a storm outside, find an indoor option that works as well. The therapist should keep this in mind when helping clients work on distress tolerance.

• Core Mindfulness – Mindfulness is a method adopted from Eastern world practices with its roots in Buddhist philosophy. It has been utilized for over 2500 years. The emphasis is to focus on one thing at a time and remain in a nonjudgemental frame of mind. Mindfulness begins with a set of skills and practices like grounding and meditative examples, but the ultimate goal is for mindfulness to become a way of being that weaves into your daily life. To be mindful is to be aware and in the present moment as much as possible. Of course, the average individual (or even the exceptional individual) can’t maintain mindfulness at all times. However, the more often the individual can draw on this life skill, the less distressing they often find life to be. After all, anxiety, sadness, and regret are all often tied to focusing on negativity from the past or expecting negativity in the future. The present moment rarely holds more than a small measure of true distress.
• Interpersonal Effectiveness – Often when individuals struggle with regulating themselves, they are surrounded by chaotic and destructive relationships as well. Their friendships, partnerships, and family relationships tend to be unhealthy and shallow, never allowing the individual to learn healthy interpersonal skills. An important aspect of DBT is teaching skills to improve the individual’s ability to interact healthily with others. DBT teaches skills like conflict resolution, how to ask for what you need, and how to listen effectively. When combined with the other core skills taught in DBT, this leads to a significant improvement in all areas of the individual’s life.
• Emotional Regulation – It’s important to remember that many individuals are not taught how to effectively manage their emotions growing up and this is not a skill that we are born with. Unless an individual intentionally works on improving emotional regulation, they are left with the behaviors they learned in childhood. Often these behaviors are maladaptive. The anxiety of any kind sends the body into the fight, flight, or freeze response mode. This model is not conducive to rational thought or logic. Individuals must first learn skills like deep breathing, box breathing, grounding, or other sensory processes and then make these things their first response to heightened emotions. DBT recognizes this and incorporates these skills into training. Additionally, it is not enough to simply return to a calm state. You should be able to name the emotion and identify the trigger that dysregulated you. Remember, this doesn’t mean that the individual has the excuse or should expect others to completely avoid that trigger. The individual needs to learn to understand why it is a trigger and gain control of whatever is contributing to this switch.