Dialectical behaviour therapy (A Comprehensive Guide)

This guide includes Dialectical behaviour therapy’s (DBT) basic information.

The whole therapy cannot be summarized in a single guide but the essence and gist of it is covered here.

DBT, or dialectical behaviour therapy, is an extension of cognitive-behavioural therapy.

It mainly aims to train individuals to use healthy coping strategies, how to control emotions, improving interpersonal relations and how to live in the present.

Dialectical behaviour therapy was initially proposed for treatment of borderline personality disorder but was later modified for conditions like eating disorders and substance abuse in which people display self-destructive behaviours.

Dialectical behaviour therapy is also occasionally used to manage PTSD.

History

dialectical behaviour therapy was developed In the late 1980s, Dr. Marsha Linehan and colleagues developed dialectical behaviour therapy when they found out that CBT by itself was not as successful as expected in treating patients with BPD.

As a result, they incorporated various techniques and improvised a treatment plan that was specific to the distinct needs of the patients with BPD.

dialectical behaviour therapy is stemmed from a philosophical process called dialectics.

Dialectics is centred around the theory that everything is made up of opposites and that change happens when one of the opposing forces is based on the concept that everything is composed of opposites and that change occurs when one opposing force is more powerful than the other.

This is an academic term is depicted through thesis, antithesis, and synthesis.

To be more specific, the theory of dialectics has three primary assumptions.

  • Everything is interconnected.
  • Change is constant and inescapable.
  • Opposites can be combined and mixed to develop a closer approximation of the truth.

Another concept that was put forth by Linehan and her team was the technique of validation.

Linehan and colleagues discovered that alongside the boost for change, validation worked to make the patients more likely to cooperate and less likely to suffer distress at the notion of change.

In this technique, the therapist gives validation to the actions of the person that they “make sense” in the context of the person’s experiences without necessarily agreeing that the actions are the right tactic to solving the problem.

What’s Unique About Dialectical Behavioral Therapy?

The term “dialectical” originates from the concept that when two opposites, acceptance, and change, are brought together in therapy, it gives us better results than using either one of them separately.

A unique feature of dialectical behaviour therapy is that it focuses on reassuring the patients by providing acceptance of their experience as a way of balancing the work needed to change the negative behaviours.

dialectical behaviour therapy consists of following the four parts:

  • Individual therapy
  • Group skills training
  • Phone coaching, if needed for crises between sessions
  • Group consultations for mental health providers to stay motivated and discuss cases they are dealing
  • Patients are given homework of practising new skills which include tracking behaviours, urges, emotions and skills like lying, self- injury, or self-respect by filling out ‘diary cards‘.

How Dialectical Behaviour Therapy Works

dialectical behaviour therapy is now practised as a standard part of CBT.

When dialectical behaviour therapy is used with a person, they will have to participate in three therapeutic settings.

The first setting is a classroom where an individual learns behaviours and skills by interacting with different people, role-playing and doing homework assignments.

This meet up is typically done on a weekly basis for 2 to 3 hours.

Next is one to one therapy session with a professional in which the person reflects on the learned behavioural skills and incorporates them into their life challenges.

This goes hand in hand with the classroom work, happening once a week for about 60 minutes.

Lastly, phone coaching is done in which the person calls their therapist in between sessions for guidance on how to cope with a tricky present situation.

While the structure and goals in group training sessions, individual psychotherapy and phone coaching my differ, the following characteristics of dialectical behaviour therapy are found in all three therapeutic settings

Support: a person learns to identify strengths and positive traits and is encouraged to develop and use them

Behavioural:  person is encouraged to evaluate problems and maladaptive behaviour patterns and substitute them with healthy, effective ones

Cognitive: focus is put on modifying those beliefs, behaviours and thought patterns that are unhelpful and ineffective

Skill sets: New skills are learned and practised to improve capability

Acceptance and change: Strategies are taught that aid in tolerating and accepting oneself and one’s life as well as bringing positive behavioural and interpersonal change in life.

Collaboration: a person is taught to communicate effectively and work together as a team (therapist, group therapist, and psychiatrist).

Dialectical Behaviour Therapy Strategies

Four basic strategies are taught to people undergoing dialectical behaviour therapy to effectively change their behaviour:

Core Mindfulness

All elements of dialectical behaviour therapy have mindfulness as one of the core ideas.

Other techniques taught in dialectical behaviour therapy have it as their foundation because it aids in the acceptance and tolerance of the powerful emotions that they may feel when they expose themselves to distressing events or challenge their habits.

It involves the nonjudgmental capacity to pay attention to the present moment, experiencing one’s own emotions and senses to the full, but still having perspective.

Through practising mindfulness, people become more aware of their surroundings through the senses of touch, smell, sight, taste, and sound. Mindfulness depends heavily on the principle of acceptance, which is also referred to as “radical acceptance”

Skills in Mindfulness are:

It begins with being attentive to your breathing. Pay attention to the sensation of inhaling and exhaling, observing your belly rise and fall as you breathe.

“What” skills

“What” skills refer to what you do when you are practising mindfulness: observe, describe, or participate.

These activities are carried out one at a time. Observe is purposefully paying attention to the present moment.

Describe is putting into words your observations. Participate to immerse completely into the activity at the moment.

“How” skills

“How” skills refer to in what manner or how one observes, describes, and participates during the practice of mindfulness.

Whether the individual takes a nonjudgmental stance (“nonjudgmentally”), focuses on a single thing at the moment (“one-mindfully”), or is doing what works (“effectively”).

These “how” skills might be done simultaneously rather than one at a time like the “what” skills.

Distress Tolerance

The strategy of distress tolerance works by teaching self-acceptance and acceptance of the present circumstances.

In particular, it involves learning how to survive and bear crises utilizing four techniques: self-soothing, distraction, thinking of pros and cons, and improving the movement.

Practising the techniques of distress tolerance gives the ability to prepare for any extreme emotions in advance and to deal with them with a more constructive and lasting outlook.

Skills in Distress Tolerance:

ACCEPTS for Distraction

When temporary distraction is needed from upsetting emotions, this skill comes in use.

Activities – Using of enjoyable positive activity

Contribute – providing help to other people or your society

Comparisons – Comparing oneself with those that are less fortunate than you or to your previous time when things were worse

Emotions (other) – provoking sense of humour or happiness with corresponding activities to feel something different

Push away – Set one’s situation at the back of the mind for some time, putting your mind to something else temporarily

Thoughts (other) – Forcing mind to think about other things

Sensations (other) – perform an activity that gives a strong feeling different than the current one, like eating something spicy or taking a cold shower

Putting Your Body in Charge

The idea is to provide distraction for you by permitting emotions to follow the body: If you’re in your house, go outside.

If you’re sitting down, stand up and start walking. Run up and down the stairs.

Interpersonal Effectiveness

Many interpersonal problem solving and assertive training classes use similar interpersonal response patterns like the ones taught in dialectical behaviour therapy skills training.

These response patterns have strategies that are effective for coping with disputes, saying no and asking assertively for what is needed.

The interpersonal effectiveness model puts focus on events in which the aim is to oppose the change someone is attempting to bring like saying no, or to bring change in oneself, for instance requesting someone for something to do.

The skills are practised to help maximize the odds of achieving one’s goals in any given situation, while not harming the relationship or one’s self-worth all at once.

Interpersonal Effectiveness Skills:

DEAR MAN – expressing your needs to the other person

This acronym is applied to help a person to get what they want when asking.

Describing a situation with a factual statement

Expressing the emotions being experienced while the event happened, why it is a problem and the feelings about it.

Assertiveness by given an open and specific expression of what changes in behaviour you are looking for.

Reinforcing the stance by telling what would be the positive result if you get what you want.

Mindfulness. Awareness of the situation by focusing on what one wants and disregard distractions through validation/empathy and redirecting back to the point.

Appearing calm and collected, even if you do not feel so.

Negotiating with the hesitant person and reach a mutual compromise with them that makes you comfortable too.

GIVE

These sets of skills help in the maintenance of one’s interpersonal relations with family, friends, romantic partners or even coworkers.

These skills are to be used in dialogue or conversation with others.

Gentle:  talk in a gentle manner rather than in a judging or attacking one.

Interest:  Listen with interest to the other person and do not interrupt them while speaking.

Validate:  give acknowledgement and validation to the emotions and thoughts of the other person.

Easy: attempt to have an easy-going attitude. Smiling through the conversation and keeping it light-hearted.

Emotion Regulation

People with BPD and with suicidal ideations experience more intense emotions and are more labile in general.

They feel anger, intense frustration, depression and anxiety to a greater degree.

Emotional regulation trains you in controlling your emotions as well as their intensity, when to express them, and how to react to them.

Once you learned to recognize and cope with negative emotions such as anger, you become less vulnerable to emotions and experience more positive emotions. 

Dialectical behaviour therapy includes the following skills for emotion regulation:

  • Emotional identification and labelling of emotions.
  • Identifying obstacles to changing emotions
  • Reducing vulnerability to emotion mind
  • Increasing positive emotional events
  • Increasing mindfulness to current emotions
  • Taking the opposite action
  • Applying distress tolerance techniques
Sample Exercise: Opposite Action

Identify what emotions you are feeling and apply the opposite.

For example, if you feel upset and want to stay away from friends and family, you rather do the contrary and make plans to socialize with them.

Is Dialectical Behaviour Therapy Right for You?

Although a major part of research has placed focus on the success of dialectical behaviour therapy with BPD, suicidal ideation, self-harm.

PTSD and substance abuse, Dialect While the majority of research to date has focused on the effectiveness of dialectical behaviour therapy for people with borderline personality disorder, as well as co-occurring thoughts of suicide and self-harm, dialectical behaviour therapy, was also proved to work with various other mental health conditions such as:

  • Generalized anxiety disorder
  • ADHD
  • Substance use disorder
  • Binge eating disorder
  • Major depressive Disorder
  • Bipolar disorder
  • Bulimia
  • Suicidal and self-harming behaviour
  • Post-traumatic stress disorder

Research has also shown that the effectiveness of dialectical behaviour therapy is not altered by age, gender, sexual orientation, and race/ethnicity.

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Conclusion

Dialectical Behavior therapy is a kind of cognitive behaviour therapy initially developed as a therapeutic treatment for borderline personality disorder.

It consists of a variety of techniques like Mindfulness, distress tolerance techniques and emotion regulation techniques.

It has been proven to be effective with problems that are emotional in nature.

Frequently Asked Questions for Dialectical Behaviour Therapy

How long does it take dialectical behaviour therapy to work?

It takes almost about 6 months to get a command over all DBT’s skills.

Sometimes, patients like to continue to treatment after that mainly in cases of BPD but usually, the therapy goals are met by the end of 6 months.

Is DBT a suicide prevention treatment?

No, it does not mainly focus on suicide prevention.

The main goal of DBT is to make life worth living for a person by teaching skills and techniques to cope with maladaptive thoughts or behaviours so he or she does not want to kill himself.

How DBT is different from other therapies?

There are many differences in DBT and other forms of therapies but the major one is that DBT consist of two types of therapies that are used simultaneously; group therapy and individual therapy.

How successful is DBT?

Process of DBT lasts for a year or two depending on the client and severity of his or her symptoms but it has been proven that DBT groups had a much lower dropout rate than any other therapy.

Additionally, success does not entirely depend on the therapy but the client you are dealing with and the therapist’s own professional skills.

Please feel free to ask any questions in the comments section below.

References

Very Well Mind

BPD Global

Mind.org

Behavioural Tech.org

Recommended Readings

The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance by Matthew McKay

DBT® Skills Training Handouts and Worksheets, Second Edition

DBT Skills Training Manual, Second Edition: 9781462516995: Medicine & Health Science Books

DBT Made Simple: A Step-by-Step Guide to Dialectical Behavior Therapy (The New Harbinger Made Simple Series)

Doing Dialectical Behavior Therapy: A Practical Guide (Guides to Individualized Evidence-Based Treatment)

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