What is Dialectical Behavior Therapy?

The Bottom Line

Very simply, Dialectical Behavior Therapy, or DBT, is about learning to live a balanced life. More technically, it is an evidence-based therapy designed to help people manage intense emotions, impulsive behaviors and difficult relationships. It was originally developed to help individuals who were suicidal or self-injured, but since then we have learned that DBT skills can help people with a lot of different problems, including those with addiction, eating disorders and emotional dysregulation. DBT skills are practical strategies to help people settle down, communicate more effectively, tolerate distress or discomfort, and better manage their emotions. DBT skills fall under core areas:

Mindfulness – Mindfulness skills teach us to be fully present in the current moment and help us learn to non-judgmentally observe what is happening in and around us.

Distress tolerance – Distress tolerance skills help us to “bear pain skillfully.” They help us manage our emotions and behaviors when we don’t get what we want, or can’t get our needs met right away. These skills are also thought of as “coping skills.”

Emotion Regulation – Emotion regulation skills are those that help us manage our internal and external circumstances, and keep us from being vulnerable to stress and pain. These skills involve getting enough rest, taking medications, eating right, exercising, etc.

Interpersonal Effectiveness – Interpersonal effectiveness skills enable us to communicate our feelings and needs to others in an appropriate and effective way. These skills can improve our relationships and help us feel more connected to other people.

DBT Skills can be taught in individual and group settings. Ideally, people who need to learn these skills will have an individual therapist and a group in which to learn and practice. Generations Counseling Services offers a group in their Greenwood, Indiana office. For more details, call us at 317-743-8202, or email us at: [email protected].

Digging Deeper

While you may not be familiar with Dialectical Behavior Therapy, or DBT, you may have heard of Cognitive Behavior Therapy (CBT). The basic idea of CBT is that our thoughts, feelings and behaviors are interrelated, and if we change one, it will impact the others.

Individuals who use CBT learn to identify negative thinking patterns and core beliefs (called schemas) and then find ways to behave differently. Or, a person decides to behave differently (“fake it ‘til you make it”). These new behaviors create better feelings which result in more effective thinking. Regardless of the order, new ways of thinking and behaving inevitably have an impact on the way we feel. 

Here’s an example: let’s say I’m in bed at 6am on a rainy Monday morning.  I lay there thinking about how busy my day is and how much I hate the rain outside. I think about how hard it’s raining and I start feeling depressed. The more depressed I feel, the deeper I burrow under the covers. The more I burrow, the worse I feel. The cycle could continue all morning, but let’s say I pick up my phone and read a text message from my Aunt Martha, who’s been confined to bed for a couple weeks. I start thinking about poor Aunt Martha, and my attitude shifts. I think about how grateful I am to be healthy, and how happy I am that both my legs work. I look outside at the rain and think about how green the grass is going to get and how much I enjoy hearing the pitter-patter on my window.

That shift in thinking motivates me to sit up and plop my feet on the floor. I decide to take a shower, and before I know it, I’m feeling more hopeful and positive about my day.

Changing my thinking from dread to gratitude gives me motivation to make a small change in my behavior, which results in a drastic improvement in my feelings. This is an over-simplification, of course, but it is CBT in a nutshell.

DBT is a cousin of CBT. It was originally developed to treat chronically suicidal individuals, many of whom were diagnosed with Borderline Personality Disorder (BPD), and has since become the gold-standard treatment for this population.

How it all began

In the late 70s, a psychologist named Marsha Linehan worked with young women who suffered from chronic suicide attempts, suicidal ideation, and non-suicidal injury (she would later realize these women met the criteria for BPD). Although she was a behaviorist who used the prevailing CBT model at the time, she found traditional treatments to be extremely ineffective for these individuals. They seemed to be getting stuck on the idea of change. This is a problem, because traditional psychotherapy models are focused on helping the client create inner change, which hopefully results in external change. However, when Linehan’s clients were challenged to change their perspective, they reacted by becoming angry or dropping out of treatment. Linehan eventually found that the focus on change was invalidating. Linehan defines invalidation as a childhood environment in which caregiver’s response(s) ignore, minimize, or punish a child’s inner emotional experiences.

Validation is a big deal, because Dr. Linehan found that individuals diagnosed with BPD typically grew up in invalidating environments. (Invalidation can encompass physical, emotional and sexual abuse and neglect, as well as a lack of connection with caregivers. Invalidation can be real or imagined – we know that if a person doesn’t perceive his or her environment as validating, the damage can be just as significant.)

Imagine then, if a therapist (or therapy modality) is invalidating, such as Linehan found CBT to be, the clinician may actually be re-playing childhood trauma in the very environment where the person is supposed to receive help. For obvious reasons, this is not good.

In addition to the invalidation, Linehan also realized that there were some complicated dynamics between the therapist and client. When clients didn’t want to do something, they found a way to get the therapist to “let them off the hook.” Maybe the client would say the work was too difficult, or that no one understood them, or would simply change the subject. Unintentionally, the therapists would stop focusing on change, then the clients would go on having all the same problems. Since chronic suicidal thinking was one of their problems, this was a big deal. In addition to suicidal thinking, Linehan’s clients had a host of other problems as well, and CBT seemed to lack the depth to help them find workable solutions to all these issues.

Thankfully, instead of giving up on these challenging cases, Linehan took the very effective behavioral components of CBT and added two critical concepts: acceptance and dialectical thinking. 

Acceptance refers to accepting things as they are, not as we want them to be. It involves learning to accept things we can’t control and accepting the need to change. It also requires a person to learn to be more self-accepting. Practicing self-acceptance, it turns out, is quite validating, and can be a doorway to change.

Dialectical thinking is a philosophical concept that refers to the process of finding truth between two seemingly opposed ideas. Simply put, dialectical thinking allows a person to find a balance between two things that seem like opposites. For example, I can be angry with my best friend for forgetting my birthday, and I can also feel a deep fondness for her at the same time. While these feelings feel like opposites, there are kernels of truth in both. (This is important, because people who have trouble regulating their emotions often think in very “all-or-nothing” ways – they either feel “angry” or “fond of”. It is very difficult for them to feel both, and in fact, trying to manage these opposite feelings tends to create a lot of anxiety.)

Linehan brilliantly integrated acceptance and dialectical thinking into the existing CBT model and created a new treatment model that teaches individuals to think more flexibly and look for ways to solve their own problems.

If you are looking for ways to better manage your emotions, your behaviors and your relationship, DBT may be a great therapy for you. Don’t hesitate to call or email us if we can help.

Need more? If you are feeling stuck and need some outside help in managing your communication, emotions, or relationships, our team at Generations

Counseling is available! Give us a call at 317-743-8202 or email at: [email protected] today.

Photo by Martin Sanchez on Unsplash