Dialectical Behavior Therapy (DBT) is an empirically tested therapy for Borderline Personality Disorder (BPD). This is the second part in a series about DBT and BPD.

A Life Worth Living

DBT was developed in the 1980’s by a psychologist named Marsha Linehan. Dr. Linehan is a gifted clinician who has tremendous compassion for chronically suicidal and self-injuring individuals, many of whom are young women. (In a 2011 interview published in the New York Times, Dr. Linehan disclosed that she also has suffered from the symptoms of BPD.)

She believes that many of these individuals were raised in “invalidating environments,” meaning they did not feel seen or understood by their caregivers. This can happen through emotional and physical neglect or abuse, trauma, or the unintentional absence of a caregiver (through death or other separation), but it can also be the perception of invalidation — meaning that the person did not experience others as nurturing or validating, even if they were trying.

A strict behaviorist, Linehan found that the traditional therapies, particularly Cognitive Behavioral Therapy (CBT), were not working with clients who exhibited more intense emotions and behaviors. It was as if their emotions (and often rigid thinking patterns) blinded them to a more effective way of coping, which kept them from being able to live the lives they wanted to. Linehan’s ultimate goal was to help individuals learn how to build a life worth living.

To help, she introduced the concepts of dialectical thinking, mindfulness and radical acceptance to the existing concepts of CBT. Her hope was to find a way to open the door to new ways of thinking and behaving, which would help her clients reach that goal of building a life worth living.

Dialectical Thinking

In philosophy, a dialectic is a term describing the concept that two things that seem like opposites can be true at the same time. Thinking dialectically means accepting the “both/and” of seemingly opposing ideas and recognizing that it is possible to hold different feelings or thoughts simultaneously.

For example, on a rainy day I can want to stay in bed under the covers and do nothing, while also wanting to go out to brunch with a friend.

Part of me wants to stay home, part of me wants to go out. Both feelings are valid.

Individuals with BPD have a very difficult time reconciling these two realities, and often find themselves choosing one to the distress and detriment of the other. For example, they may choose to stay in bed, but then beat themselves up all day because they cancelled on their friend.

Thinking in a “both/and” way can allow for more effective decision making and maybe can help the person figure out ways to do both, instead of opting for “either/or.”

Radical Acceptance

Radical acceptance says, “It is what it is.” (I think this happens to be one of those profound clichés in life that is both annoying and comforting.) Radical acceptance says, “I don’t like it, I don’t want it, I’m not happy about it…but it is on my plate and there’s not a thing I can do about it.”

Sometimes we think of this as leaning into instead of away from our difficult circumstances. Radical acceptance is more than just accepting something as tough, it’s about working with the difficulty instead of against it.

Resilient people seem to practice radical acceptance with ease (although it is often anything but easy). They understand and accept that suffering is a part of life, and in order to move forward, they have to, at some level, embrace hardship. The story of Joni Eareckson Tada illustrates this beautifully.

In 1967, Joni (pronounced Johnny) was a vivacious 17-year-old who loved sports of all kinds, especially horseback riding and swimming. Everything about her life changed in an instant when she was in a horrific diving accident that left her paralyzed from the neck down.

In her book, Joni, she writes about the loneliness and despair she experienced throughout her long days of recovery. She described being literally attached to her hospital bed, where nurses would turn her every few hours to avoid bedsores. One night as she lay face-down, staring at the cold tile hospital floor, she contemplated suicide. She could not fathom anything she had to live for, and desperately wanted to end her suffering. Her darkest hour was the realization that she was so dependent on others, she couldn’t even kill herself.

Thankfully, Joni’s severe depression eventually lifted, and in her book, she describes her miraculous emotional recovery (which she credits much to her strong faith in God). Although she never has regained any feeling below her neck, over the past 50 years she has written over 50 books, won numerous awards, and has become an outspoken advocate for the physically disabled.

One significant path to her healing was her art. A gifted artist before the accident, Joni eventually learned to draw again with her mouth, and her artwork is stunning. (You can learn more about Joni at her website.)

This is a great example of radical acceptance.

(It is very important to note that acceptance in this case does not mean approval. Radical acceptance means that we are committed to making the best of a bad situation, not that we are in support of it.)

Radical acceptance says: somehow this terrible thing ended up on my plate. So what am I going to do with it?

The Four Skills Modules of DBT

DBT builds on these concepts as the foundation and teaches four skills modules to help clients cope more effectively with intense thoughts, moods, emotions and behaviors. The skills modules are mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness.

Mindfulness

Mindfulness is both simple and complex. It is the art of being fully present in the current moment without judging anything or trying to change it. When we teach mindfulness to our clients with BPD, the goal is to help them notice and observe what is happening without saying that it is good or bad or making any other kind of judgment. Over time, the practice of mindfulness can help calm our bodies and settle dysregulated nervous systems.

In the example of staying in bed vs going out for brunch, it is helpful to think of each option as a legitimate choice. Deciding what to do becomes less about determining the “right” vs the “wrong” decision, rather, what is most effective. (We often teach clients to do this by considering the pros and cons of each choice and weighing which one will help them most reach their longer term goals.)

One of the goals of DBT is to find “Wise Mind” — that part of you that makes effective choices, not just choices that reduce discomfort or make things easier in the short run. Wise mind helps us think about long-term goals while honoring our need for comfort or ease in the short-term.

Mindfulness can help us access this part of ourselves.

Distress tolerance

Distress tolerance is about learning how to manage yourself effectively even when you’re physically or emotionally miserable. Think of it as getting through the crisis without doing anything to make it worse.

Like mindfulness, the focus of distress tolerance is not on changing the moment, but in learning to co-exist with it. Through distress tolerance we learn to practice radical acceptance. We try to focus on the big picture rather than the little moment, and try to adopt a more long-term view.

This can mean learning to find appropriate distractions, or shifting our focus to the things we can change, or have control over, rather than the elements of life that are out of our control.

Emotion regulation

In and of themselves, emotions are not bad or problematic. But just like fire or water, they need to be contained (or regulated).

“Hot,” or intense emotions can get the best of all of us from time to time. When we feel intense emotions, things can get out of control – kind of like throwing fuel on an already burning fire.

Emotion regulation is about becoming more emotionally literate and about learning to cool off hot emotions so they can be managed more effectively.

Emotion regulation teaches us (often by making appropriate changes in our routines or our environments) to think and behave differently, which hopefully leads to changes in feelings and and subsequent behaviors.

Interpersonal effectiveness

When we are emotionally unstable, our relationships tend to take a big hit.

Interpersonal effectiveness is about learning to communicate our thoughts, feelings and needs in an effective way, which hopefully means that we are more likely to hear and be heard. When interpersonal effectiveness is integrated with the other skills, we learn to tolerate rejection and cope effectively even if the other person doesn’t honor our requests or communication.

Being skillful and effective in our communication increases our peace of mind, because when we use the skills effectively, we don’t have to regret acting out of control.

Interpersonal effectiveness also involves establishing and maintaining limits and boundaries on ourselves and others.

This is Complicated – How Does a Person Figure All This Out?

These skills are not only useful for individuals who struggle with emotion regulation, but their caregivers and loved ones as well. I have seen many individuals and their families benefit from the regular practice of DBT skills.

And while the overall concepts of DBT are pretty simple, it can be incredibly complicated to learn how to put them into practice. The skills have to be practiced over and over in order for them to become truly effective.

There are some very helpful books and websites available on the subject (some I’ve listed below) to help you learn more.

Additionally, we have several therapists in our office trained in DBT, and we can offer 1:1 sessions as well as groups that meet periodically.

If you are in the Greenwood/Indianapolis, Indiana area and are interested in learning more about DBT, give us a call at 317-743-8202 or email [email protected]. Even if you’re not in the area and have questions, we would be glad to help if we can.

A Few Helpful Resources

Behavioral Tech – This is the official DBT website.

Building a Life Worth Living – the memoir of DBT founder, Marsha Linehan

The High Conflict Couple: A DBT Guide to Finding Peace, Intimacy and Validation – by Alan Fruzzetti – this is an excellent resource to help couples integrate DBT principles into their relationships

Borderline Personality Disorder in Adolescents: a Complete Guide to Understanding and Coping When Your Adolescent Has BPD by Blaise Aguirre, MD – a very helpful guide for parents

Family Connections – provides education, skill training, and support for individuals who are supporting someone affected by Borderline Personality Disorder (BPD) or Emotion Dysregulation (ED), or exhibiting BPD/ED traits.