Dialectical Behavior Therapy: An Essential Guide for Therapists

What is DBT?

Dialectical behavior therapy (DBT) was developed by Marsha Linehan in 1993. It is based on classical cognitive behavior therapy (CBT).  DBT combines standard cognitive behavioral techniques for emotional regulation with other concepts such as distress tolerance, acceptance, and mindful awareness.

DBT is an evidence-based psychotherapy, which has shown well-documented efficacy. DBT was designed to help people suffering from borderline personality disorder. It has been effective in treating people with overwhelming emotions and self-harm, suicidal ideation and substance abuse. Research shows that DBT strengthens a person’s ability to handle distress without losing control or acting destructively.

About borderline personality disorder

Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability in:

  • affect regulation,
  • impulse control,
  • interpersonal relationships,
  • self-image.

Clinical signs of the disorder include:

Borderline clients represent 2%-3% of the general population. Suicide is a risk among BPD patients in particular. Statistics show from 8% to 10% of completed suicide attempts in these patients.

BPD patients tend to be considered as “difficult” by healthcare professionals (Bourke & Grenyer, 2010). This is currently changing due to DBT’s proven efficacy, and training programs.

DBT vs CBT: How do they compare?

In the traditional Cognitive Behavior Therapy (CBT) approach,  one of the most commonly used techniques is cognitive restructuring. Therapists make key questions related to the content or to specific dysfunctional or distorted thoughts. These include, for example: “Where’s the evidence for your conclusion?” or  “Is there another way of thinking about this?”.

On the other hand, Dialectical Behavior Therapy (DBT) focuses on mindfulness, being aware or attentive to the current situation. It was developed by Marsha Linehan who, based on classical cognitive behavior therapy (CBT), emphasizes dialectic balancing and integration of seemingly opposite ideas.

DBT teaches skills to control intense emotions, reduce self-destructive behaviors and improve relationships. CBT consists of challenging the emotions of individuals, in particular when it is hard for them to accept their beliefs as real and reasonable.

DBT differs from CBT in seeking a balance between changing and accepting beliefs and behaviors.

DBT is an alternative to CBT to treat clients with extreme emotional reactivity and high sensitivity to vulnerabilities, like perceived rejectionIt shares with CBT the importance of creating a warm and collaborative relationship with the client. This allows them to work together to solve problems, providing new ways of accepting what is causing stress, and helps patients change in a positive manner.

CBT DBT
Faulty thoughts corrected by learning CBT combined with Buddhist meditative practices
Thinking can be wrong Thinking is dialectical
Change Radical acceptance

How effective is DBT? Evidence of Efficacy

Multiple studies support the efficacy of DBT. It has been proven effective for: borderline personality disorder, post-traumatic stress, self-harm, and suicidal behavior.

  • Bohus et al. (2004) conducted a controlled trial in an inpatient setting. They found that people in therapy who received three months of DBT improved at a greater rate than those who received treatment as usual.
  • Linehan et al. (2006)  conducted a study which suggests that DBT may be effective in reducing suicide attempts. In this study, patients who received DBT were half as likely to attempt suicide. Psychiatric hospitalizations were reduced and patients were less likely to drop out of treatment, compared to those who received psychotherapy from expert professionals in treating self-harm and suicide.

In DBT, balance is the key

DBT is based on a continuous oscillation between change and acceptance.

The balance between change strategies and acceptance strategies constitutes the fundamental dialectic that gives name to the treatment.

Dialectic means “to evaluate and integrate contradictory ideas and facts in a vision that solves the apparent contradictions”.

There are three basic assumptions:

  • All things are interconnected.
  • Change is constant and inevitable.
  • Opposites can be integrated to form a closer approximation.

The balance between these positions, that is the dialectic, implies that the therapist must “sustain change and acceptance simultaneously in therapy”. 

The Four Components of DBT

DBT can be thought of as a “program”, given the different tools, modalities and resources it uses.

Teaching skills is one of the main objectives and requires time and practice. Therefore, DBT will typically last for a year at a minimum.

The four components of DBT include:

  • Individual therapy
  • Group skills training
  • Intersession contact
  • Peer consultation

Individual therapy

The objective of individual therapy is to enhance motivation towards addressing life-threatening behaviors, therapy-interfering behaviors and quality-of-life-interfering behaviors.

Individual therapy involves weekly standard DBT sessions, where dialectical and validation treatment strategies take place. 

Group skills training

The objective group skills training is to enhance the patient’s capabilities by learning new skills and generalizing these to other aspects of their lives.

Group skills training involves structured and psycho-educational group activites. Group sessions act as a complement to individual therapy, these are generally offered on a weekly basis and can take between 2-2.5 hours.

The group uses a Skills Training Manual. This manual includes four skills modules: mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness.

Intersession contact: phone coaching

DBT is the only model of psychotherapy in which intersession contact is mandatory for treatment.

The objective of intersession contact is to ensure skills generalization through coaching. Helping the client to develop skills in order to prevent life-threatening behaviors (for example, nonsuicidal self-harm) or seeking unnecessary hospitalizations.

Intersession contact involves coaching calls that often last between 10 and 20 minutes.

The client does not need to be in crisis in order to contact the therapist and the frequency should decrease the more the client spends time in the program.

Peer consultation

The objective of peer consultation is to provide support for therapists, as well as enhancing their skills and motivation in standard DBT.

Peer consultation involves weekly peer team meetings, during which DBT therapists provide case consultation and support related to treatment.  LPR

The 4 Stages and Targets of DBT

There are 4 stages of treatment in DBT, defined by the severity of the patient’s behaviors. Therapists use this framework to support patients in achieving certain goals.

  • Stage I: behavioral
  • Stage II: emotional and cognitive
  • Stage III: interpersonal
  • Stage IV: sense of self

There is no specific time frame designed for each one of the stages. The amount of time spent within each stage will be determined by these goals.

Stage I: Behavioral

At this stage, a behavior is out of control: patients may try to kill themselves, engage in self-harming behaviors or use drugs and alcohol excessively. Self-destructive behaviors can also occur at this stage, and mental illness could be described as “being in hell”.

The goal is to achieve behavioral control.

Stage II: Emotional and Cognitive

Leaving life-threatening behaviors behind, patients may feel as living in quiet desperation. Past trauma and invalidation may make suffering continuous for them, this can cause the patient to inhibit emotion experiencing. Post-traumatic stress disorder (PTSD) is addressed at this stage.

The goal is to move from quiet desperation to normative emotional experiencing and expression.

Stage III: Interpersonal

Stage III is aimed at rebuilding a life and achieving skills generalization in relationships and working environments. Life goals should be defined and self-respect has to be built. Finding peace and happiness becomes the main focus.

The goal is to achieve ordinary happiness and unhappiness. LPR

Stage IV: Sense of self

This stage is optional and is often used with those patients who seek further spiritual fulfillment or a sense of connection to a greater whole. Those patients usually cannot stay with just a life of ordinary happiness and unhappiness from the previous stage. LPR

Goal: Moving from a sense of incompleteness towards a life that involves an ongoing capacity to experience joy and freedom.

DBT patients usually do not have just one problem that needs to be addressed, but several ones. They may present multiple problematic behaviors that do not fall under one specific diagnosis.

How can the therapist know where to start?

DBT uses a target hierarchy to determine the order in which problems should be addressed:

  1. Life-threatening behaviors. These behaviors, like with fire, should be extinguished first due to the extreme risk to the patient’s life they entail. They can include all forms of suicidal and non-suicidal self-harm, suicidal ideation and communication, as well as other behaviors the patient engages in for the purpose of causing him/herself physical harm.
  2. Therapy-interfering behaviors.  They interfere with the client receiving effective treatment. These behaviors can be on the therapist’s or the client’s end, and include arriving late or even missing sessions and a non-collaborative stance in working towards treatment goals.
  3. Quality-of-life-interfering behaviors. These are other types of behavior that prevent the patients from having a reasonable quality of life, such as problematic relationships, mental illness or housing crises.
  4. Skills acquisition. This category refers to the need for patients to learn new skillful behaviors in order to replace ineffective ones and, in consequence, achieve their goals. These skills are aimed at assisting in building relationships, managing emotions and effectively dealing with different life problems. 

All these should be addressed at Stage I.

PTSD should be addressed at Stage II, where the goal is to end the continuous suffering and move to normative emotional experiencing.

In a typical session, many of the above-mentioned problems can be present. For example, the patient may talk about a recent breakup and how he or she self-injured to alleviate the emotional pain. In that case, the therapist will first target self-harm (life-threatening behavior) and then the breakup (quality-of-life-interfering behavior).

The underlying notion is that DBT will be ineffective if the patient is dead or does not attend sessions.   

What are the goals of DBT?

Standard DBT focuses on the following 5 essential functions:

  1. Improving behavioral capabilities by increasing skillful behavior
  2. Increasing motivation to change through contingency management 
  3. Confirming generalization of skillful behavior to the natural environment
  4. Structuring the treatment environment so that it reinforces functional rather than dysfunctional behaviors
  5. Enhancing therapist capabilities and motivation to treat patients effectively.

Enhancing Skills: The 4 Modules in DBT skills training

Mindfulness module

Mindfulness refers to putting one’s mind in a state of fullness. In other words, it is the ability to live being intentionally aware of the present moment, without judging and or staying attached to a particular moment.

There are 3 ways to practice mindfulness:

  • Participate
  • Observe
  • Describe

Participate

Participate refers to doing only one thing at a time. The idea is to allow the client to let go of self-consciousness, judgments and fears; and to fully concentrate in a particular activity.

Examples for clients:

    • “Participating in only one activity might be different depending on which activity you are doing.”
    • “For example: If you are eating a piece of chocolate cake, you are just eating a piece of chocolate cake. You shouldn’t be watching TV, sending messages to your friends, and listening to music while you eat the cake.”

Observe

Observing means directly noticing the sensory experience. It is composed of what a person feels, tastes, sees, touches and hears without putting any labels on it, reacting to it or judging it.

Examples for clients:

    • “At first, it can be challenging for our minds, because they try to label what is happening rather than just being with the bare sensations of an experience.”
    • “One example of observing is when you are listening to music, imagine that your body is permeable to sounds and observe each one of those sounds. You can also experience observing while breathing gently and focusing your attention on the movement and pauses of your belly, how it rises and falls during your breath.”
    • “You can practice Observing by doing this activity of mindful breathing.”

Describe

Describe is based on observing. To describe is to put words to what you are observing, whether it is a thought, a sensation or an emotion.

This is a powerful tool to help clients identify and distinguish thoughts and feelings from real facts. Highly sensitive clients can use this skill to reduce their reactivity. When someone is describing, facts need to be checked to avoid jumping into wrong conclusions about oneself or others.

Examples for clients:

    • “Your own interpretations or assumptions shouldn’t be considered to describe what you observe. Just stick to the facts.”
    • “For example: imagine that your mind is a railroad and your thoughts and emotions are wagons of a train that circulates on it, describe them and label them as they pass by.”
    • “Imagine that your mind is a river, thoughts and emotions are ships that sail through it. You are sitting in front of it on the grass, you can describe them while they pass.”

Interpersonal effectiveness module

One of the greatest struggles of borderline or emotionally dysregulated patients is related to the difficulty in asking for what they want. Therefore, the interpersonal effectiveness module focuses on setting clear goals (Objective effectiveness), maintaining self-respect (Self-respect effectiveness) and having conflict-free relationships (Relationship effectiveness).

Dialectical behavior therapy uses acronyms to help clients remember the skills tied to each type of effectiveness.

Objective effectiveness: DEAR MAN

Be effective in maintaining your rights and wishes

  • D – Describe the situation
  • E –  Express how you feel about it
  • A –  Ask for what you want
  • R –  Reinforce the other person
  • M –  Be Mindful
  • A –  Appear confident
  • N-  Be willing to Negotiate

Relationship effectiveness: GIVE

“Act in such a way that you can maintain good relationships, that others feel comfortable with you and with themselves”

G – Be Gentle, avoiding attacks and judgmental statements.

I –  Act Interested by listening to the other person and not interrupting

V- Validate and acknowledge the other person’s wishes, feelings, and opinions

E- Easy manner, smiling and using humor

 

Self-respect effectiveness: FAST

“Act in such a way that you can maintain self-respect”

F- Be Fair to yourself and to the other party

A- Apologize less

S- Stick to your values

T-  Be Truthful and avoid exaggerating

 

3. Distress tolerance module

Distress tolerance is geared toward increasing a person’s tolerance of negative emotion, rather than trying to escape from it. The skills taught in this module help the client survive crises from a more manageable emotional place.

This module explores six different skills:

  • TIPP (Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation).
  • ACCEPTS (Activities, Contributing, Comparisons, Emotions, Push away, Thoughts, and Sensation).
  • Improving the moment
  • Self-soothing
  • Focusing on pros and cons
  • Radical acceptance

TIPP

T- Temperature

The body increases its temperature when disturbed. If the client uses cold water or ice, it could decrease the body’s temperature and help him/her to cool down (both physically and emotionally).

  • Instructions:
    • Change your body temperature using cold water or ice.

I- Intense exercise

Increasing oxygen flow helps decrease stress levels. Exercising intensely will help the body release energy that can sometimes be stored due to strong emotions.

  • Instructions:
    • Walk quickly, climb the stairs, run on the spot.

P- Paced Breathing

Steady breathing reduces the body’s fight or flight response.

  • Instructions:
    • Breathe in while counting to 5. Hold. Then exhale to the count of 7.

P- Paired muscle relaxation

This is a variation on progressive muscle relaxation. It is useful to gear towards physically relaxing major and minor muscle groups in the body, to help release tension and stress.

  • Instructions:
    • Tense an area of your body, notice the tension and hold it for 5 – 10 seconds.
    • Then, release the tension and relax for 5 -10 seconds.  
    • When relaxing the muscle, breathe out and say the word “Relax”.

 

ACCEPTS

This set of skills stands for Activities, Contributing, Comparisons, Emotions, Push Away, Thoughts and Sensations.

The goal is to keep the clients’ emotions under control and help them tolerate negative emotions until they can solve the problem.

Activities

Any healthy activity can be useful for this purpose. Activities that keep clients busy and keep their mind off the negative emotion will help. If they finish with one activity they should move to a new one. Examples include: cooking a delicious dessert, washing dishes and going for a walk.

Contributing

Giving service to other people can help clients get their mind off the problem at hand. When we help others, we can feel good about ourselves and that helps us to deal with stress.

Comparisons

Compare the client’s life with previous times when he or she has faced difficult situations and challenges. If this is the most intense situation they have ever experienced, they need to review the TIPP skills. They can also make comparisons with other people who have suffered more than them. The aim of this skill is to add a different perspective to what they are experiencing at the moment.

Emotion

When you help the client to add a dose of the opposite emotion you can reduce the intensity of the present one.  For example, if the clients feel depressed, make them search on the internet for adorable puppies. This will make them feel less depressed.

Push Away

A good strategy when clients cannot deal with a problem is to push it out of their minds for a short period of time, by distracting themselves with other activities, thoughts or being mindful. You can also advise them to set a time to come back to the issue, so they will be relaxed in the meantime.

Thoughts

A client’s negative or anxious thoughts can be replaced with activities that make their minds busy, such as solving a puzzle or crossword. These distractions will help them avoid life-threatening behavior until they can reach emotional regulation.

Sensations

The five senses can help clients self-soothe during times of distress. Activities that appeal to their senses, like smelling a nice perfume or listening to music, can help them cope with the problematic situation.  

 

Improving the moment (IMPROVE)

The goal of IMPROVE skills is to reduce the intensity of their emotions in any kind of situation and feel more in control of their lives.

This set of skills stands for: Imagery, Meaning, Prayer, Relaxation, One thing in the moment, Vacation, and Encouragement.

IMAGERY MEANING PRAYER RELAXATION ONE THING IN THE MOMENT VACATION ENCOURAGEMENT
Use imagery to distract or soothe.

“Think about a calm or positive place in your mind”

Try to find meaning in painful situations

“What can I learn about this stressor that can help me in the future? ”

The client can open him/herself up to God’s will and accept the situation as it is. Relax the body using techniques of yoga, breathing, a hot bath, and a relaxing walk. Focusing on one thing in a stressful situation can provide means to settle down.

“Just this moment”

Taking a short break away from the crisis can help you gain some perspective

“Calling a friend, going for a walk or visiting a new place”

For the clients to validate themselves, as well as their abilities.

“I’ve already been through many other painful experiences, and I’ve survived”

 

Self-soothing

Using the body’s senses can quickly reduce the intensity of negative emotions during a crisis. Senses are a perfect tool that you are always carrying with you. This tool can help reduce stress and the intensity of a situation. It is important to focus on only one sense at a time, to be able to incorporate mindfulness into the self-soothing skill.

  • Sight: This sense is very useful to focus on something else. Make clients focus on some pictures that they like or in the color of the room.
  • Hearing: Make them listen to the sounds of birds, or their favorite song, for example. Any sound is useful to practice hearing.
  • Taste: Some small pieces of food that taste good can give them something pleasurable to focus on while they are going through a tough moment. A candy or piece of gum will work. It’s not necessary for them to eat a whole meal.   
  • Touch: Make the clients feel the sense of touch by noticing the tip of their fingers when touching something or taking a warm bath or shower it is possible.
  • Smell: No matter if it is good or bad smell, clients should focus on the scent that is in the air. They have to think about the smell, and break it down into its components.
  • Movement: This is the sixth sense introduced by DBT. Emotional state can be altered by body movements, so you can suggest clients to take a walk around the block or dance. You can even make them play a football match to make them conscious about movement.  

 

Focusing on the pros and cons

Taking into account the difficulties of making a wise decision, a Pro and Con List can help the clients weight out the consequences of their decisions.

Make clients do a few bullet points in their mind. Or, if they prefer, write that list down on a piece of paper, so they can dig deep in their minds. Make them think about which behavior is the best for them. This can help them fight impulsive urges and their negative outcomes.  

 

Radical acceptance

Distress tolerance involves Radical acceptance. It means that clients are able to acknowledge situations in their lives that they have no control over and fully accept them as reality, rather than fighting against them by denying that they exist or complaining because they are unfair.

 

4. Emotion regulation module

The objective of regulating emotions is to teach clients how to handle negative and overwhelming emotions, while increasing positive experiences. There are three main goals in emotion regulation:

Understanding emotions

Negative emotions should not be avoided. They are a normal part of life, but they should not take full control either. The client must learn how to label his/her emotions.

In DBT, clients are often taught to be specific about how they feel. Instead of describing it as “I feel bad”, they have to put a label to it, like feeling “anxious” or “frustrated”.  

Reducing emotional vulnerability

The purpose of this skill is to build positive experiences in order to balance life negative feelings and incidents. Patients are encouraged to plan daily experiences that they can enjoy and expect, such as playing sports, spending time with good friends or reading a book. Engagement in these activities has to be mindful, completely centering attention on the activity they are currently doing. They are also encouraged to set long-term goals that can provide positive experiences to them.

The acronym for the skill set aimed to reduce emotional vulnerability is PLEASE MASTER:

PL – represents taking care of physical health and treating pain and/or illness.

E – is for eating. Having a balanced diet and avoiding excessive sugar, fat, and caffeine.

A – stands for avoiding alcohol and drugs, which only exacerbate emotional instability.

S – represents getting regular and adequate sleep.

E – is for exercising regularly.

MASTER – refers to having daily activities that build confidence and competence.

Decreasing emotional suffering

Two skills compose this module: letting go and taking opposite action.

  • Letting go

This skill refers to being aware of the current emotion by being mindful, labeling it, and then letting it go—rather than avoiding, dwelling on, or fighting it. This might involve taking a deep breath and visualizing the thought or feeling floating away, or picturing the emotion as a wave that comes and then goes.

  • Taking opposite action

This skill requires to engage in behaviors that would come naturally when experiencing the emotion that is in direct contrast to the current one.

The patient will be required to label the emotion and letting it go. The main purpose is not to deny the current emotion, but to act opposite to it. This way, the negative emotion will be less intense. For example, if a patient is very angry she could try to speak in a soft and calm voice.

Additional resources: The DBT Travel Guide

This app is meant for people with borderline personality disorder (BPD) who take part of a Dialectical Behavior Therapy (DBT) program or want to start one. DBT provides tools for people with BPD to regulate their emotions and control their urges.

The app provides information about DBT and BPD. The DBT Travel Guide contains more than 200 different skills and mindfulness exercises. The app can provide support in moments of crisis through its crisis section.

For DBT therapists, the app contains a ‘think of’ scheme, full of practical guidelines.

Link: https://itunes.apple.com/be/app/dbt-travel-guide/id959541436?mt=8

Additional scope of DBT: Treating anxiety

The dialectical behavior therapy skills workbook for anxiety: Breaking free from worry, panic, PTSD, and other anxiety symptoms:

This is a manual for people with anxiety disorder or people who experience anxiety symptoms that interfere with their day-to-day life. People can benefit from four simple skills that therapists use with their clients. These easy-to-learn skills are at the heart of dialectical behavior therapy (DBT).

Link: https://bit.ly/2NWiT87

Conclusion

In conclusion, DBT focuses on teaching skills used to cope with stressful situations. The ultimate goal of DBT is that the patient is able to create a life worth living.

 

References

 

  1. Linehan, M. M. (1993). Dialectical behavior therapy for treatment of borderline personality disorder: implications for the treatment of substance abuse. NIDA research monograph, 137, 201-201.
  2. Bass, C., van Nevel, J., & Swart, J. (2014). A comparison between dialectical behavior therapy, mode deactivation therapy, cognitive behavioral therapy, and acceptance and commitment therapy in the treatment of adolescents. International Journal of Behavioral Consultation and Therapy, 9(2), 4.
  3. Kienast, T., Stoffers, J., Bermpohl, F., & Lieb, K. (2014). Borderline personality disorder and comorbid addiction: epidemiology and treatment. Deutsches Ärzteblatt International,111(16), 280.
  4. Bohus, M., Haaf, B., Simms, T., Limberger, M. F., Schmahl, C., Unckel, C., … & Linehan, M. M. (2004). Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behaviour research and therapy,42(5), 487-499.
  5. Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., … & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of general psychiatry,63(7), 757-766.
  6. Linehan, M. M., Cochran, B. N., & Kehrer, C. A. (2001). Dialectical behavior therapy for borderline personality disorder.Clinical handbook of psychological disorders: A step-by-step treatment manual, 4, 365-420.
  7. Linehan, M. (2014). DBT? Skills Training Manual. Guilford Publications.
  8. Chapman, A., Gratz, K., & Tull, M. (2011). The dialectical behavior therapy skills workbook for anxiety: Breaking free from worry, panic, PTSD, and other anxiety symptoms. New Harbinger Publications.