Dialectical behavioral therapy (DBT) is a form of therapy created in the 1970s by Marsha Linehan.1 It branches off of cognitive behavioral therapy (CBT), which focuses on the connection between thought patterns and behaviors. In DBT, patients identify target behaviors that have proved disruptive to their lives. They then look at what triggers those target behaviors and learn adaptive, alternative skills to use instead.
How exactly does DBT work, what does it treat, and what do you need to know going in? In this blog, we’ll provide an overview of DBT so you can know what to expect.
What Is Dialectic Behavior Therapy?
To understand DBT, you have to understand what a dialectic is in the first place. Hegel describes a dialectic as a process of thought in which both the thesis and antithesis can be seen as part of a larger truth, called the synthesis. That two seemingly opposite statements can both be true can be distressing for some and cause conflict.
Psychoanalyst Melanie Klein expanded on this concept of dialectics with her Object Relations Theory.2 According to the Object Relations Theory, an infant would project aggressive and self-destructive impulses, as well as self-loving drives, onto their mother’s breast — their primary source of sustenance. When their mother was loving and caring, she embodied the “good breast,” while a neglectful or disappointing mother would embody the “bad breast.” To infants, these seem to be two different people. As we grow, we come to understand them as one person, which can be uncomfortable to grapple with.
Adults vacillate between integrating two dialectics and “splitting,” a psychological term that refers to the thought process of switching between idealization and devaluation. Splitting is a common way to cope with uncomfortable dialectics such as loving someone and being furious with them. This splitting can lead to interpersonal difficulties and emotional dysregulation.
DBT helps patients learn how to accept both parts of a dialectic and navigate the emotions that come with that.
What Is DBT Good For?
Marsha Linehan developed DBT while studying suicide ideation, but today DBT is primarily used to treat borderline personality disorder (BPD). However, it can also be used to help with:
- Substance abuse
- Eating Disorders
- Relationship issues
- Depression and anxiety
- PTSD
The skills taught in DBT are overall good skills to practice in life, no matter what your mental health might look like.
Group Therapy vs. Individual Therapy
DBT has two different forms: group therapy and individual therapy. In full DBT, patients attend one hour of individual therapy and 1-2 hours of group therapy each week.
In group therapy, therapists will lead the group through each of the DBT modules in order. They will give examples of how the skills in that module might work and ask for examples from the group. They will then assign homework to practice those skills throughout the week.
In individual therapy, the therapist and patient will create a hierarchy of target behaviors. These begin with life-threatening behaviors such as self-harm or suicide attempts, followed by therapy-disrupting behaviors, and finally quality of life altering behaviors. These behaviors are identified and tracked on a diary card. Every time the trigger behavior occurs, the patient will record what triggered it and what their emotional response was, as well as the behavior itself.
DBT skills can also be worked into other forms of therapy, including CBT, ACT, interpersonal therapy, and more.
Modules of DBT
The main structure of DBT comes down to its four modules: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness.
Mindfulness
Mindfulness is all about being grounded in the present moment, as well as the sensations around you and the emotions within you. By being more mindful, you become more aware of the ways that your emotions contribute to your target behaviors. Mindfulness goes beyond meditation, though that can be a useful skill. It may take the form of:
- Describing your emotions
- Self-compassion meditation
- Breathwork
- Beginner’s mind (being aware of your past experiences while treating the present as a potentially new experience)
The goal of mindfulness is to decrease negative ruminations about trauma, negative interactions with others, and catastrophic thinking about the future. Rather than focusing too much on the past or future, you stay in the present.
Distress Tolerance
Distress tolerance provides skills and resources to help patients cope through moments of crisis. The goal is to improve the moment slightly so as to remove the patient from crisis and decrease the risk of self-harm or target behaviors. Distress tolerance skills will not make you feel all better, but they may make you better able to manage how you feel.
Some distress tolerance skills may include:
- Pressing an ice pack to yourself rather than self-harming
- Repeating coping statements
- Creating self-soothing habits
- Practicing radical acceptance
Radical acceptance is not pretending to be okay with everything that is happening. Rather, it is the acceptance that those things are happening, regardless of your feelings about them. It is also an acceptance of your feelings. This can be a hard skill to practice but may be useful, especially in crises related to grief or trauma.
Emotion Regulation
Next comes emotion regulation, which is all about putting your emotions more within your control. In some cases, this may mean actively working to change your emotions about a situation by changing your outlook or the way you cope with that situation. In others, it might be proactively being aware of what makes you emotionally vulnerable or dysregulated — such as poor diet or lack of sleep.
Emotional exposure is also an important part of emotion regulation: training yourself to sit with your emotions without reacting. Another skill in the emotion regulation module is “opposite action to emotion.” This skill requires you to first sit with your emotion and recognize how you feel. Accept that feeling. Then act in a way that opposes that feeling. For instance, if you are feeling depressed, you may want to cancel plans and isolate, even though having that social support may help you feel better. The opposite action to that emotion would be to honor your plans and see your friends, despite how you feel.
Interpersonal Effectiveness
Interpersonal effectiveness is all about your interactions with others and how you express your needs. This module is not about making sure you always get what you want, but rather communicating clearly to negotiate and compromise with others in an effective way.
Most people are either passive or aggressive by nature, and both of these social temperaments can be pushed to an unhealthy degree. With interpersonal effectiveness, you want to find the middle ground — being assertive, but willing to compromise. Think about the values that are most important to you and stand up for them, without jumping to combativeness.
Active listening is also an important part of interpersonal effectiveness. Without listening, it can be impossible to reach a fair compromise. Finally, interpersonal effectiveness focuses on doing what is effective in a situation, rather than acting on impulse.
Final Tips About DBT
DBT is not an easy therapy to work with. It’s hard, and you aren’t wrong to acknowledge that it’s hard! But with practice, it does get easier and the results are worth it.
Make sure to set reasonable expectations. None of the DBT skills make you feel 100% better, and you may need to use some skills all day long. When you find yourself frustrated, ask yourself, “Did it not help at all or did it help a little?” The more you practice those skills, the more they’ll be able to help.
Some skills will work better for certain personalities and situations than others. Every patient is different, so it’s important to figure out what works best for you and stick with it.
Finally, find the right therapist to support you on your DBT journey. Rivia Mind has a number of skilled and compassionate clinicians who are experienced with DBT. Contact us today to learn more or schedule an appointment.
Resources:
- DBT Skills Training Handouts and Worksheets – Marsha Linehan, 2014
- Melanie Klein’s Object Relations Theory – Simply Psychology
