Dialectical Behavioral Therapy, also known as DBT, is a popular therapeutical and evidence-based treatment approach that many psychotherapists use to help treat clients dealing with anxiety disorders, depressive disorders, personality disorders, and much more. In my opinion, there are not many people that wouldn’t benefit from the skills within the DBT model. Dialectical Behavioral Therapy can be quite the mouthful to verbalize, an easier way to think of this and my preferred way is, “Developing Balance Therapy.” If you consider yourself someone who deals with anxiety, depression, extreme and/or overwhelming emotions, suicidal thoughts, personality disorder characteristics, trouble in interpersonal relationships, DBT may be a great therapeutic option for you.
DBT was developed in the late 1970s by Marsha Linehan, who is both a psychologist and author. Since then, many revisions and updates have been added and/or improved within the DBT framework. Marsha Linehan dealt with her own share of mental health difficulties and suicidal thoughts which played a role in her creating this therapeutic approach many years following treatment and hospitalizations. This therapeutic approach was formed directly from her (1) experience as a mentally sick patient that was institutionalized for 2 years and even some time afterward and (2) her studies and research throughout her college and doctoral studies in psychology. In Marsha Linehan’s memoir, she notes that during her experience in institutions she vowed to herself that she would study psychology and one day help people escape “their own hell” as that is how it felt for her.
DBT has two important concepts including, (1) to build a life worth living, one must learn how to accept things as they are, and (2) change is absolutely needed for any growth and happiness in life. These two concepts can be quite the conundrum, as opposing forces are working together to both accept where we are in life and/or situations AND ALSO acknowledge that change is absolutely a non-negotiable to move forward to a life worth living. An important concept of DBT is practicing and acknowledging that things can coexist. Situations and life experiences/emotions do not have to be EITHER/OR, they can be BOTH/AND.
Examples are as follows:
“We can be both sad and grateful that a relationship in our life has ended.”
“We can be both angry that a situation occurred and happy that it led us to where we are today.”
“We can both understand that in order to live a healthy, toxic free lifestyle we cannot be friends with certain people and know that we have joyful memories with these people to look back on.”
“We can be both happy our child is getting married and/or leaving the home and sorrowful that we will not be needed as much.”
“We can be both excited to accept a new job offer and fearful/anxious of the intense work it may bring.”
“We can acknowledge the amount of work we are doing in various areas of our life and know that we can try harder and increase motivation for change.”
“I don’t want to do this, and I am going to do it anyway.”
“I disagree with you, and I understand your perspective on things.”
DBT has 4 main modules within its framework which are the following: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness. Continue reading below to see a breakdown of each module:
What is Mindfulness?
An easy way to understand what Mindfulness is and means is the following breakdown:
(1) To be Aware (2) Of the Present Moment (3) On Purpose (4) and Without Judgement
Mindfulness can be quite challenging. Many of us are going and going throughout our days, almost living on autopilot; we tend to have our habits and structure and sometimes can get uncomfortable with “boredom.” From my experience as a psychotherapist, mindfulness tends to be one of the most difficult skills to begin practicing. We first must have awareness, which can be especially challenging if we have a stressful or traumatic past (or day-to-day life) that has led us to dissociate from everyday life. A good way to begin “being aware” is bringing this awareness to things we already do during the day, like eating or drinking. While doing either of these activities, take a moment to become aware of what your senses are telling you: what are you tasting, what is the texture, what is the flavor, etc. This awareness can also help our bodies with digestion, as we tend to eat slower and more ‘mindfully’ when we become more aware. The next (2) and (3) can come somewhat naturally as we become more aware due to being in the ‘present moment’ and practicing this ‘on purpose.’ I find the last part (4) ‘without judgement’ to be somewhat challenging at times personally and from my experience with clients. The ‘without judgement’ piece can be challenging due to the constant stream of thoughts in our mind. Many people confuse this with trying to quiet their mind completely, which a lot of the time, can be quite the challenge or even nearly impossible. My suggestion with this piece and within the DBT framework is to “just notice” the thoughts streaming in and out of your mind, trying not to attach much meaning to these thoughts as we have thousands of them each day. Overall, trying to be a neutral party or bystander as these thoughts stream in and out of our mind.
A few skills within DBT that can help with mindfulness:
· Wise Mind
· What and How Skills
· Thought Defusion
· Any Breathing Technique
· Progressive Muscle Relaxation
· Mindful Walks
You can find many of these skills on the DBT website listed in the resources section below as well as in any of the DBT workbooks I mention.
What is Distress Tolerance?
Distress Tolerance in DBT means one’s ability to handle situations that may bring up emotions and/or possible difficulty. Being able to handle situations adequately can increase a person’s ability to stay within their “window of tolerance.” This allows a person to not feel completely overwhelmed or shut down due to whatever the situation or trigger may be at the time. Having skills to help with distress tolerance is necessary to move forward in any situation. Many times, we get into overwhelming situations and/or shut down because we do not have the necessary emotional tools or were never given them from an emotionally regulated parent. Understanding that it is normal to experience discomfort, pain, and any other emotion in certain situations is vital in allowing ourselves to take the next step to regulate our bodies. Developing a list of coping skills for yourself is necessary, DBT’s Distress Tolerance module has a variety of skills to add to your own personal toolbox. It is important to practice and be aware of a variety of skills because some skills can work better when we are in certain situations where others (or longer skills) may not be appropriate at the time. Below is a list of Distress Tolerance Skills, more information on these skills can be found in the resource section with specific websites and workbooks to refer to.
A few skills within DBT that can help with Distress Tolerance:
· HALT
· STOP
· TIPP
· ACCEPTS
· Creating a Distraction Plan
· IMPROVE
· Visualizations and Imagery
· Affirmations
· Radical Acceptance
· Behavior Chain Identification
· Soothing self with 5 senses
What is Emotion Regulation?
Emotion Regulation in DBT is all about learning how to identify and name your emotions as they are happening to you as well as afterward. Being able to understand your emotions and put a label to them can assist us in understanding what is going on in our body, understand the situation better, and process what happened in the situation. Our emotions are what make us human, we all have emotions, and each emotion serves a purpose, even if that emotion doesn’t “feel good” in the moment. There are many goals in the module of emotion regulation but a few of them are as follows: (1) to learn how to name the emotion we are feeling, (2) understand what our emotions are doing for us, (3) decrease our emotional vulnerability, (4) decrease our emotional pain and cope more efficiently.
A few skills within the DBT module that can help with Emotion Regulation:
· Emotions Wheel/List
· Understanding common myths about emotions
· Module for describing emotions
· PLEASE
· Opposite Action
· SMART Goals
· Building Mastery
· Coping Ahead of Time
· Check The Facts
What is Interpersonal Effectiveness?
Interpersonal Effectiveness in DBT is focused on helping clients understand their current relationships while also expanding relationships and/or creating new ones. Interpersonal Effectiveness skills help us to understand what healthy relationships look like, what toxic relationships may be present in our lives, how to compromise with people close to us, how to set boundaries to ensure self-respect, and lastly, how to effectively communicate with others. Within the Interpersonal Effectiveness Module, we must take inventory of what our current and past relationships have been like, this can require us to do much self-reflection especially if we find ourselves in the same, frustrating patterns within our relationships. This module allows us to look at old relationship patterns, identify our needs, identify overwhelming emotions associated with relationships, identify any negative predictions we may have, and realize when situations may be far beyond our control. This module helps us understand ourselves better, in terms of our needs/wants/and values.
A few skills within the DBT module that can help with Interpersonal Effectiveness:
· Identifying Values
· Values Assessment
· Noting your needs
· Understanding your legitimate rights
· DEAR MAN
· GIVE
· FAST
· Understanding Self Validation & Levels of Validation
· Intensity Factors
· How to say “No”
· Boundaries & Setting Boundaries
How do I find a DBT Group and/or a DBT trained and informed psychotherapist?
If you are looking to begin individual psychotherapy, it is important to look at potential therapist profiles. If you are looking for someone who practices DBT, you can specifically look for “DBT” mentioned on their profile or “DBT-Informed/Trained.” Specific modalities of what the psychotherapist uses with clients should always be listed in their website profile, as well as psychology today profile. For DBT groups in your area, googling is always a wonderful resource as well as looking at local hospitals and group/private practices. If you already have an individual therapist, this could be something they could assist you with, as well.
Resources/References
Books:
Building a Life Worth Living: A Memoir By Marsha M. Linehan Developer of Dialectical Behavioral Therapy
Websites to learn more about DBT:
Websites to learn DBT Skills:
Workbooks and other resources for DBT:
The Dialectical Behavior Therapy Skills Workbook By: Liotera Murasa
Self-Directed DBT Skills: A 3-Month DBT Workbook to Regulate Intense Emotions and Create Lasting Change wit DBT By: Kiki Fehling PhD, Elliot Weiner PhD
The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises for Overcoming Trauma and Post-Traumatic Stress Disorder By: Kirby Reutter PhD, Dawn DePasquale LMHC