What Is Dialectical Behavioral Therapy (DBT) and How Does It Work?

Dialectical behavior therapy (DBT) is a type of cognitive-behavioral therapy that teaches patients the skills to manage emotions and decrease conflict in relationships.

The main goals of DBT are to:

• teach people how to live in the moment
• cope with stress in healthy ways
• regulate emotions
• improve relationships with others 

It also incorporates concepts and modalities designed to promote abstinence and to reduce the length and adverse impact of relapses.

Who Developed DBT?

DBT was developed by Marsha Linehan, Ph.D., and is influenced by the philosophical perspective of dialectics: balancing opposites. The therapist consistently works with the patient to find ways to hold two seemingly opposite perspectives at once, promoting balance and avoiding black and white—the “all-or-nothing” styles of thinking. 

DBT promotes a both-and rather than an either-or outlook. The dialectic at the heart of DBT is acceptance and change.

Patients undergoing DBT are taught how to effectively change their behavior using four main strategies:

• Mindfulness: focusing on the present and how to live in the moment.
• Distress Tolerance: learning to accept oneself and the current situation. More specifically, people learn how to tolerate or survive crises using these four techniques: distraction, self-soothing, improving the movement, and thinking of pros and cons. 
• Interpersonal Effectiveness: how to be assertive in a relationship (for example, expressing needs and saying “no”) but still keeping that relationship positive and healthy.
• Emotion Regulation: recognizing and coping with negative emotions (for example, anger) and reducing one’s emotional vulnerability by increasing positive emotional experiences.

What Can You Expect with Dialectical Behavioral Therapy (DBT)?

DBT is made up of several structures that help a patient identify strengths and weaknesses within themselves and through their relationships:

Support-oriented:

DBT is support-oriented. It helps a patient identify their strengths and builds on them so that they can feel better about themselves and their life.

Cognitive-based

DBT helps identify thoughts, beliefs, and assumptions that make life harder, such as: 

• “I have to be perfect at everything” 
• “If I get angry, I’m a terrible person” 

DBT helps patients to learn different ways of thinking that will make life more bearable such as: “I don’t need to be perfect at things for people to care about me” and “Everyone gets angry, it’s a normal emotion.”

Collaborative:

DBT requires constant attention to relationships between patients and therapists. In DBT, people are encouraged to work out problems in their relationships with their therapist and the therapists to do the same with them. 

DBT asks patients to complete homework assignments, to role-play new ways of interacting with others, and to practice skills such as soothing yourself when upset. These skills, a crucial part of DBT, and are taught regularly. The therapist helps the person to learn, apply, and master the DBT skills.

The 4 Modules of DBT

1. Mindfulness

The essential part of all skills taught is the core mindfulness skills. 

Observe, Describe, and Participate are the core mindfulness “what” skills. They answer the question, “What do I do to practice core mindfulness skills?”

Non-judgmentally, One-mindfully, and Effectively are the “how” skills and answer the question, “How do I practice core mindfulness skills?”

2. Interpersonal Effectiveness

The interpersonal response patterns –how the patient interacts with the people around them and in personal relationships — that are taught in DBT share similarities to those taught in some assertiveness and interpersonal problem-solving sessions. 

These skills include effective strategies for asking for what one needs, how to assertively say ‘no,’ and learning to cope with inevitable events.

An individual may be able to describe the right behaviors when discussing another person encountering a problematic situation but may be completely incapable of carrying out a similar set of behaviors when analyzing their own personal situation. 

The Interpersonal Effectiveness module focuses on situations where the objective is to change something (e.g., requesting someone to do something) or to resist changes someone else is trying to make (e.g., saying no). 

The skills taught are intended to maximize the chances that a patient’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the patient’s self-respect.

3. Distress Tolerance

Most approaches to treatment focus on changing distressing events and circumstances. However, they should also pay attention to accepting, finding meaning for, and tolerating distress. 

Dialectical behavior therapy emphasizes learning to cope with pain skillfully.

Distress tolerance skills grow from mindfulness skills. They have to do with the ability to accept, in a non-judgmental fashion, both oneself and the current situation. This stance is non-judgemental, but that does not mean it is approving. Acceptance does not mean approval.

Distress tolerance behaviors are concerned with tolerating and surviving crises and with accepting life as it is in the moment. 

Four sets of crisis survival strategies are taught: 

• distracting
• self-soothing
• improving the moment 
• thinking of the pros and cons 

Acceptance skills include: 

• radical acceptance
• turning the mind toward acceptance 
• willingness versus willfulness

4. Emotion Regulation

Patients benefit from assistance in learning to regulate their emotions. Managing emotions in negative situations can reduce emotional vulnerability by increasing positive emotional experiences.

Therapy skills for emotion regulation include:

• Learning to properly identify and label 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

DBT and Addiction Treatment

Elevate Addiction Services has been using DBT in our addiction treatment program, as an evidence-based treatment approach. The skills taught in DBT can be particularly helpful to individuals who are struggling with substance abuse, as this type of thinking allows individuals to see their thoughts from a new perspective. 

Learn more about how DBT can apply to addiction treatment, contact us today. 

References:

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797106/