An Overview of Dialectical Behavior Therapy (DBT)

DBT Origins and background

DBT was created by Marsha Linehan late 1980s.

The word dialectical means the practice of reaching the truth by the means of exchanging logical arguments. This can be delivered in a one to one session between client and therapist or as part of a group.

DBT was originally invented to work with those suffering from Borderline Personality Disorders and those reporting with Suicidal Ideation. And has since been used in the treatment of Post Traumatic Stress Disorder, Sexual Abuse, Substance Use Disorders, Depression, Disorders related to Binge Eating and Traumatic Brain Injury..

Trials have found it to reduce suicidal ideation and psychiatric interventions as it works to improve emotional responses to situations which create or cause harm to those accessing this type of therapy.

DBT uses logical coping mechanisms that once taught can be self-implemented through Mindfulness bringing the emotions into the here and now and improving interpersonal skills.

DBT was derived from Cognitive Behavioural Therapy (CBT) and this CBT’s origins in changing thinking and behaviours as well as the feelings that underpin both.

As CBT considers feelings and emotions. RBT is a step on from this and the therapist will carefully consider the emotional response to life events with their clients.

RBT uses what is known as a non-judgemental approach and a realistic view of life.

Addressing both painful and pain free emotions is the key. Understanding that painful emotions are a part of life and an area where no judgement should be placed is the key.

In essence this form of therapy shines a light on negative emotions (the client feels are unacceptable to society) and blows apart any conceptions of how they should be embraced.

Both negative and positive emotions are part of human life and are to be embraced. This element automatically reduces the pressure on the client. This release helps the focus to be turned into practical solutions.

Coping mechanisms can be introduced during Mindfulness sessions. If possible the client will undertake one 1-2-1 session once per week to identify any problems that arose in their day to day life.

Followed by one group session of Mindfulness to explore ways of resolving conflict and get the point of view across without argument and whilst maintaining self-respect.

Once taught the client is encouraged to follow the practices and delivery methods at home in an ongoing basis.

What is DBT and how does it work

Individual or in a group setting which will allow for participants to actively take part in therapy as well as watch the process unfold with their peers.

The 4 components of DBT are:

• Mindfulness
• Emotional regulation
• Distress tolerance
• Interpersonal Effectiveness  

Mindfulness initially starts with acceptance and the ability to identify a situation for what ‘it is’ and accept ‘it has’ happened or will continue to happen if factors do not change.

A component of acceptance related to DBT is ‘radical acceptance.’ This is concerned with accepting a situation which is either negative or positive in the same way i.e. without judgement or preconceived ideas of how it should be considered.

Once acceptance is reached Mindfulness will work more effectively. Mindfulness is the component that ties all four components together as it is during mindfulness the student can observe, describe and participate in a non-judgemental fashion a specific area such as the emotional state prior to substance use.

Mindfulness is a technique interested with the act of being in the moment or the here and now. DBT use this technique to illicit thoughtful responses rather than emotive ones.

As emotive responses can swing high or low and provoke negative outcomes. Mindfulness in DBT is about experiencing feelings and emotions with perspective and not impulse. This component draws the other ‘three’ together and effects the calming change the therapist and client are striving for.

Emotional regulation is concerned with addressing emotions that may be hypersensitive, for example, DBT was originally created for those with Borderline Personality Disorders.

It could be argued the response to certain situations is emotionally unstable i.e. the expected response does not occur.

Emotions can be either inappropriate or appropriate to the ‘situation.’

Distress Tolerance is an incredibly innovative yet productive component of DBT. Instead of following society’s norms and expectations this element is created to be non-judgemental.

Clients are encouraged to address and not suppress feelings surrounding events. And to leave any preconceived ideas of how they ‘should’ feel at the door. This area uses a non-judgemental approach so the client can learn to see a situation for what it is and not become overtly emotional when it occurs.

As they have already placed a looking glass on the situation and know what emotions they previously displayed and how they were impractical.

Interpersonal Effectiveness 

Interpersonal relates to human interactions and relationships. Interpersonal Skills are required to effectively communicate needs, wants, emotions, viewpoints and what is acceptable in the relationship i.e. the ability to say no without harming the relationship or the ability to request changes.

Through clear and effective communication. Interpersonal Skills and techniques can be taught and implemented in emotive situations resolving any interpersonal conflict.

How to implement the Four Components of DBT 

Mindfulness begins by looking at ‘acceptance’ which is required for DBT to work. Staying in denial and not accepting the good and not so good parts of character that are activated during arguments etc. is not helpful.

Radical Acceptance is required when accepting both the good and the bad parts as human as a general rule avoid focussing on the bad parts. Staying stuck in the problem and never entering the solution.

Radical Acceptance is acknowledgement in a non-judgemental manner of the bad parts. Desensitising the individual to those parts and reducing the negative hold they may have.

Mindfulness uses the theory of Acceptance and Change and has five states of change. Pre-Contemplation, Contemplation, Preparation, Action and Maintenance.  The therapist will walk their client through each stage.

Pre-contemplation usually occurs before therapy begins i.e. the client has reflected on their life and identified ‘something’ is not right. Or their way of dealing with certain situations creates animosity and hostility.

Contemplation is normally implemented by a form of research such as seeking out DBT Therapists phone numbers and considering calling them.

Preparation is calling the therapist and arranging a date and time to arrive and considering what you hope to achieve or where the problem arises.

Action is attending all DBT sessions recommended by your therapist.

Maintenance is continuing with the art of Mindfulness and incorporating this technique into daily life. Also practicing all the models within DBT at home or as situations arise.

Followed by:

Utilising ‘What’ and ‘How’ skills whilst practicing this form of meditation. The ‘What’ skills are Observe, Describe and Participate and are conducted in a non-judgemental manner. 

The ‘How’ skills are how the participate is observing, describing and participating and again are required to be ‘non-judgemental.’

What and how techniques are used to contextualise the emotions being felt with a more rounded view.

Emotion Regulation uses a technique known as Opposite Action

When previously discussing DBT the ability to change a negative and unhelpful emotion attached to a situation is a critical component to recovery.

Just as the title implies instead of reacting in the way the client always does i.e. by staying in the house. They are encouraged to do the opposite such as go outdoors for a walk to a friend’s house.

A technique known as PLEASE is also used.

PhysicaL Illness – to be treated if feeling unwell emotions may lean towards impatience and intolerance

Eating to be balanced – if over hungry feelings of tiredness or stress may occur

Avoid alcohol and drugs – as these are mood & mind altering and may affect both negatively

Sleep a balanced amount – if over tired or slept to long humans feel out of balance

Exercise to release feel good chemicals – do the opposite and get up and go.

Taking Holistic self-care will regulate emotions and when difficult interpersonal situations arise the client will already be in a more balanced place.

Distress Tolerance use a technique known as T.I.P. 

Tipping – cold water is to be placed on the face, activating the Dive Reflex and reducing the temperature of the face. This is to slow down actions

Intense Exercise – recommended for 20 minutes to burn off stress energy

Paced Breathing to regulate the internal stresses

TIP is an effective tool to use when the emotions are overwhelming to ‘stop’ the surge and return a form of balance to the individual.

Interpersonal Effective uses a technique known as DEAR MAN

Describe, the situation using facts

Express, the emotions at time of event

Assert, the conversation and ask what the person expects

Reinforce, offering a positive consequence

Mindful, avoid distractions stay focussed

Appear, to be in control of the situation

Negotiate, reach a mutual compromise

This is an effective technique that helps to break down an effective response. When trying to convey feelings at that moment in time such as what is required from the situation. Leaving the conversation feeling empowered and not inadequate.

The technique known as GIVE is also used. To:

Give, share information about life, be courteous and non-judgemental

Interested, listen to what the other person has to say, make eye contact

Validate, show empathy and understanding, use positive body language

Easy Manner, chat in a relaxed manner, use relaxed body language

GIVE is helpful when maintaining relationships, helping them to stay balanced. This technique creates mutual respect and understanding an important part of healthy relationships.

The technique known as FAST is also used.

Fair

Apologies

Stick to one's values

Truthful

In order to keep self-respect in the relationship FAST is an effective technique taught in DBT.

Examples of DBT in Action

“I need a drink to get through this situation!”

Here is the situation and response prior to DBT.

Situation – Argument with spouse

Emotional Regulation – Extreme Distress and internal Turmoil

Distress Tolerance – inability to look at the situation without judgement

Acceptance – None, straight into denial

Interpersonal – emotions are too high to talk through what needs and wants

Mindfulness – None, straight into worse-case scenario

This response is destructive in nature to the client and the person they are interacting with.

Here is the intended response after DBT.

Situation – argument with spouse

Emotional Regulation – arguments are a normal part of life use Opposite Action take a walk or some exercise calm down then re-commence conversation

Distress Tolerance – Explore good and bad truths, recognise their existence. Use TIP.

Acceptance – Of the outcomes that may occur if arguments continue

Interpersonal – Use DEAR MAN to communicate wants and FAST to keep self-respect

Mindfulness – Stay in the here and now do not reach for worst case scenarios, look at WHAT is being said and HOW – be non-judgemental.

The situation has now been addressed from a different perspective in a non-judgemental dialectal manner. The intention is a calmer response to situations that arise in daily life.

If the behaviour was to drink or used drugs to cope with an argument and the high emotions DBT will work to stop this negative cycle.

DBT is widely received in the Psychotherapy community as an effective form of therapy to support those with ‘emotional’ problems and the inability to effectively deal with difficult situations.

Their response may baffle the person they are arguing with causing harm to both parties. After diagnosis such as: Borderline Personality Disorder, Suicidal Ideation, PTSD, Depression or Substance Use Disorder (problematic alcohol and drug use).

The individual can access this form of therapy form a registered and qualified therapist.

DBT is not delivered over one session and attendees are usually expected to attend until both they and the therapist believe significant changes have been made. And they feel they can self-implement.

Frequently Asked Questions