Dialectical Behavior Therapy
l DBT is a broad-based cognitive-behavioral treatment
originally developed by Marsha Linehan for chronically suicidal individuals
diagnosed with borderline personality disorder (BPD).
l Consisting of a combination of individual psychotherapy,
group skills training, telephone coaching, and a therapist consultation team,
DBT was the first psychotherapy shown through controlled trials to be effective
with BPD.
l DBT, including DBT skills training, is based on a
dialectical and biosocial theory of psychological disorder that emphasizes the
role of difficulties in regulating emotions, both under and over control, and
behavior.
l In DBT, Emotion dysregulation has been linked to a variety
of mental health problems stemming from patterns of instability in emotion
regulation, impulse control, interpersonal relationships, and self-image. DBT
skills are aimed directly at these dysfunctional patterns.
l The overall goal of DBT skills training is to help
individuals change behavioral, emotional, thinking, and interpersonal patterns
associated with problems in living.
The Dialectical theory:
As its name suggests, DBT is based on a dialectical world view.
“Dialectics” as applied to
behavior therapy has two meanings: that of the fundamental nature of reality,
and that of persuasive dialogue and relationship.
Dialectical perspectives on
the nature of reality and human behavior share three primary characteristics.
1.
Much as
dynamic systems perspectives do, dialectic stresses the fundamental
interrelatedness or wholeness of reality: This means that a dialectical
approach views analyses of individual parts of a system as of limited value
unless the analysis clearly relates the parts to the whole. Thus dialectics
directs our attention to the individual parts of a system (i.e., one specific
behavior), as well as to the interrelatedness of the part to other parts (e.g.,
other behaviors, the environmental context) and to the larger wholes (e.g., the
culture, the state of the world at the time).
2.
Reality
is not seen as static, but as made up of internal opposing forces (thesis and
antithesis) out of whose synthesis evolves a new set of opposing forces. A very
important dialectical idea is that all propositions contain within them their
own oppositions. Dialectics, in this sense, is compatible with psychodynamic
conflict models of psychopathology. Dichotomous and extreme thinking, behavior,
and emotions are viewed as dialectical failures. The individual is stuck in
polarities, unable to move to syntheses.
3.
The
third characteristic of dialectics is an assumption, following from the two
characteristics above, that the fundamental nature of reality is change and
process rather than content or structure. The most important implication here
is that both the individual and the environment are undergoing continuous
transition.
Thus DBT does not focus on
maintaining a stable, consistent environment, but rather aims to help the
client become comfortable with change.
Biosocial Theory: How Emotion Dysregulation Develops
l Biological Vulnerabilities (the “Bio” in the Biosocial
Theory)
Dispositions to negative
affectivity, high sensitivity to emotion cues, and impulsivity
are biologically based
precursors to emotion dysregulation. The biological influences include
heredity, intrauterine factors, childhood or adulthood physical insults
affecting the brain, and the effects of early learning experiences on both
brain development and brain functioning. A dysfunction in any part of the
extremely complex human emotion regulation system can provide the biological
basis for initial emotional vulnerability and subsequent difficulties in
emotion modulation. Thus the biological disposition may be different in
different people.
l The Caregiving Environment (the “Social” in the Biosocial
Theory): The contributions of the social environment, particularly the family,
include a tendency to invalidate emotions and an inability to model appropriate
expressions of emotion; an interaction style that reinforces emotional arousal;
and a poor fit between the child’s temperament and the caregivers’ parenting
style.
l This final point is emphasized here because it highlights
the biology × environment transactions that shape both child and caregiver
behaviors. In theory, a child with low biological vulnerability may be at risk
for BPD and/or high emotion dysregulation if there is an extreme discrepancy
between child and caregiver characteristics, or if the family’s resources are
extremely taxed (e.g., by a family member’s alcoholism or a sibling with
cancer).
Treatment functions
DBT clearly articulates the
functions of treatment that it is designed:
l Improve motivation: to enhance an individual’s capability by increasing
skillful behavior
l Enhance capabilities: to improve and maintain the client’s
motivation to change and to engage with treatment
l Ensure generalization: to ensure that generalization of
change occurs through treatment even in non therapy environment
l Enhance environment: to enhance a therapist’s motivation to
deliver effective treatment; and
l Maintain skills and motivation of treatment providers: to
assist the individual in restructuring or changing his or her environment in
such a way that it supports and maintains progress and advancement toward goals.
The skills taught to
clients reflect a key dialectic described earlier, the need for clients to
accept themselves as they are, and the need for them to change. Hence there are
sets of acceptance skills as well as change skills.
For any problem
encountered, effective approaches can include acceptance as well as change. Skills
are further divided into the four skills modules by the topics they address:
l Mindfulness
l Distress tolerance
l Emotion regulation
l Interpersonal effectiveness
“Pretreatment” in DBT refers to all sessions and conversations occurring
between a client and a provider until both parties have agreed that DBT is an
appropriate intervention for the client’s goals and wishes, and both parties
have agreed to work together.
There are five pretreatment
tasks:
i.
Conduct
pretreatment assessment: Evaluation
for skills training should begin with a clinical assessment, including
assessment of presenting problems and goals, past and present life- threatening
behaviors, diagnostic evaluation as needed, and evaluation of reading and
language deficits (if the client’s skills in these areas seem questionable). The
assessor should also take a general history and ask about history of previous
DBT and DBT skills training.
ii.
Determine
intensity and treatment type needed: A major function of the assessment sequence is to determine
whether the individual client needs a more comprehensive treatment than
stand-alone DBT skills training. In other words, does the person need something
more than DBT skills? The level of disorder is linked to one of four stages of
treatment in DBT. Stages of treatment are, in turn, linked to goals and
specific targets of behavior to increase and decrease.
Generally, the criteria for
putting a client in:
Stage 1: are a current
severe mental disorder, behavioral dyscontrol, and/or imminent threat to life.
Any of these conditions will prohibit working on any other goals before
behavior and functioning come under better control. In the subsequent stages
(2–4), the treatment goals are to replace “quiet desperation” with nontraumatic
emotional experiencing
Stage 2: to achieve
“ordinary” happiness and unhappiness, and to reduce ongoing disorders and
problems in living
Stage 3: and to resolve a
sense of incompleteness, and to achieve a sense of freedom and joy
Stage 4: Not all clients
enter therapy at the same stage of disorder; not all clients go through all of
the stages; and clients can vacillate between stages. The last stage helps
clients find meaning through a spiritual existence. As a result, clients gain a
capacity for experiencing joy and freedom. The goal of stage four is for
clients to garner a sense of connectedness, as they are part of a great whole.
iii. Orient client to specifics of skills training: Following assessment, the therapist should briefly present
the skills deficit model of emotional and behavioral dysregulation. The
individual pretreatment interview with the skills trainer should orient the
client to the specifics of skills training. This includes how the group (if
there is a group) will function, what the client’s and the trainer’s roles in
skills training are, and how skills training is different from other types of
therapy
iv. Develop collaborative commitment: Once you have decided to accept a person into skills
training, it is important that you yourself make a commitment to treating the
individual. Entering a treatment with reluctance, reserve, or antagonism, or on
unwanted commands from others, can markedly impair your chances of developing a
strong and collaborative relationship with your skills training participants. It
is also important to talk with potential clients about any pressures from
family members that may be the main impetus for their coming to DBT or to
skills training specifically particularly with adolescents coming to treatment
with their parents.
v.
Begin
developing alliance: Use
of standard DBT therapeutic relationship strategies, such as relationship
acceptance and relationship enhancement, is particularly important at the start
of skills training. The next task of skills trainers is to help clients see the
relevance of a skills training model to their own lives. An overview of the
skills training treatment year is given a theory of disordered emotion
regulation that stresses the role of inadequate skills is presented.
I.
Mindfulness
skills
Mindfulness skills help us
focus attention on the present moment, noticing both what is going on within
ourselves and what is going on outside of ourselves and become and stay
centered.
Core Mindfulness Skills: Three sets of skills form the backbone of mindfulness
practice:
l Wise mind: Define “wise mind” for clients as “finding inside
yourself the inherent wisdom that each person has within.”
l “What” skills : Tell clients that the “what” skills are “the
skills that tell you what you should actually do when you practice mindfulness.
There are three ‘what’
skills: observing, describing, and participating.”
l “How” skills : Explain to clients that the “how” skills are
“the skills that teach you how to practice your mindfulness skills. Without the
‘how’ skills, you can veer far away from mindfulness itself.
There are three ‘how’
skills: acting nonjudgmentally, one-mindfully, and effectively.”
II.
Distress
tolerance is the ability to tolerate
and survive crisis situations without making things worse. Also, these skills
teach us how to accept and fully enter into a life that may not be the life we
hoped for or want. The distress tolerance behaviors targeted in DBT skills
training are concerned with tolerating and surviving crises (including crises
caused by addictive behaviors) and with accepting life as it is in the moment.
By definition,
crisis survival skills
are short-term solutions
to painful situations. Their
purpose is to make a painful situation more tolerable, so that it is possible
to refrain from impulsive actions that can make the situation worse.
There are six sets of
crisis survival strategies:
l The STOP Skill: The STOP skill helps individuals refrain
from impulsive actions. STOP is a mnemonic for the following steps:
S=Stop,
T=Take a step back,
O=Observe, and
P=Proceed mindfully.
l Pros and Cons: Evaluating pros and cons is a decision-making
strategy. The focus here is on thinking through the positive and negative
consequences of acting on impulsive urges in crisis situations and of not
acting on them (i.e., tolerating distress).
l TIP skills: The TIP skills can be used to change body
chemistry quickly, so as to counteract disabling emotional arousal.
TIP is a mnemonic for:
T=Temperature, I=Intense exercise,
P=Paced breathing, and Paired muscle relaxation.
l Distracting with Wise Mind ACCEPTS: There are seven
sets of distraction skills.
The word ACCEPTS is a
mnemonic for these strategies:
A=Activities (discordant to
the negative emotion),
C=Contributing,
C=Comparisons,
E=Emotions (opposite to the
current negative emotion),
P=Pushing away from the
situation,
T=Thoughts, and
S=Sensations
l Self-Soothing: Self-soothing strategies focus on the five
senses- vision, hearing, smell, taste, and touch. They consist of sensual
activities that feel comforting, nurturing, and soothing. The body scan
meditation also falls into this category.
l Improving the moment: The final set of crisis survival
skills is an idiosyncratic collection of ways to improve the quality of the
moment.
The word IMPROVE is a mnemonic for each of these strategies:
I=Imagery,
M= Meaning,
P=Prayer,
R=Relaxing actions,
O=One thing in the moment,
V=Vacation, and
E= Encouragement.
Reality Acceptance Skills
Whereas the goal of crisis
survival is to get through the crisis without making it worse, the goal of
reality acceptance skills is to reduce suffering and increase freedom when
painful facts cannot be changed immediately, if ever.
There are five sets of
reality acceptance skills.
l Radical Acceptance: Radical acceptance is complete and total
acceptance, from deep within, of the facts of reality. It involves
acknowledging facts that are true and letting go of a fight with reality.
l Turning the Mind: The skill of turning the mind toward
acceptance is choosing to accept reality as it is. It is not itself acceptance,
but it is the first step toward acceptance, and it must usually be taken over
and over again.
l Willingness: Willingness implies a surrendering of one’s
self separateness, an entering into, an immersion in the deepest processes of
life itself. It is a realization that one already is a part of some ultimate
cosmic process and it is a commitment to participation in that process.
l Half-Smiling and Willing Hands: The skills of half-smiling
and willing hands are usually taught together and are ways to accept reality
with the body. In half-smiling, facial muscles are relaxed, with lips slightly
upturned at the corners. Because emotions are partially controlled by facial
expressions, adopting this facial expression helps clients feel more accepting.
In willing hands, the hands are unclenched, with palms up and fingers relaxed.
Willing hands are the opposite of clenched hands, which are indicative of anger
and of fighting to change reality.
l Mindfulness of Current Thoughts: Mindfulness of current
thoughts is observing thoughts as thoughts (i.e., as neural firing of the brain
or as sensations of the brain), rather than as facts about the world. This
skill teaches clients to differentiate thoughts from facts, to distance
themselves from their thoughts and become less reactive to them, while allowing
them to arise and fade away.
III.
Emotion
regulation includes enhancing control
of emotions, even though complete emotional control cannot be achieved. To a
certain extent we are who we are, and emotionality is part of us. But we can
get more control and perhaps learn to modulate some emotions.
The specific DBT emotion
regulation skills taught in this module are grouped into the following four
segments:
l Understanding and naming emotions: identifying the functions
of emotions and their relationship to difficulties in changing emotions; Understanding
the Functions of Emotions; Identifying Obstacles to Changing Emotions; Identifying
and Labeling Emotions.
l Changing unwanted emotions: The second segment of the module
focuses on changing emotional responses by:
- Check the Facts: Sometimes just knowing the true facts can
change how you feel.
- Problem Solving: is changing your emotions by avoiding,
modifying, or solving the
event prompting the emotion.
- Opposite Action: is changing your emotions by acting
opposite to your emotional
urge to do something.
For eg: Tell participants: “When fear is not justified,
approach what you fear rather
than avoid it. Do what you are afraid to do rather than
avoid it.”
- Building Mastery and Learning to Cope Ahead
- How to Build Mastery: Do at Least One Thing Each Day
- Plan for Success, Not Failure
- Gradually Increase the Difficulty over Time
- Look for a Challenge
- Taking
Care of the Body (PLEASE Skills): Exercise: PLEASE Skills: Treat Physicalillness,
balance Eating, avoid mood Altering substances, balance Sleep, and get Exercise.
l Managing extreme emotion: It deals with how to manage very
difficult emotions. Decreasing emotional suffering through mindfulness to the
current emotion is an important skill here, as well as learning how to identify
one’s skills breakdown point and then turning to the distress tolerance skills
when that happens.
Exercise: “Use crisis survival skills”
- TIP Skills for Changing
Body Chemistry: Change your body temperature by putting cold water on your
face, or by having a warm bath or foot soak.”
- Distraction from the
Event Prompting the Emotion
“Shift your attention: Move
your mind away from what is distressing you.”
“Focus your mind on
something else, anything else.”
“Leave the situation
completely.”
- Self-Soothing through the
Five Senses
“Look at something pleasant
(vision).”
“Listen to soothing music
or other pleasant sounds (hearing).” “Touch something soft or soothing.”
“Smell something pleasant.”
“Eat or drink something
good (taste).”
- Improving the Moment You
Are In
“Imagine being somewhere
else or in a different situation.”
“Pray”
“Find relaxing things to
do.”
IV.
Interpersonal
effectiveness skills help
us maintain and improve relationships both with people we are close to and with
strangers. It deal with identifying factors that contribute to interpersonal
effectiveness, as well as things that interfere with being effective.
l Objectives Effectiveness: teaching specific skills for
getting what one wants, summarized with the mnemonic DEAR MAN: Describe,
Express feelings, Assert wishes, Reinforce, (stay) Mindful, Appear confident,
and Negotiate.
l Relationship Effectiveness: Skills for keeping a
relationship, summarized with the mnemonic GIVE: (be) Gentle, (act) Interested,
Validate, (use an) Easy manner.
l Self-Respect Effectiveness: skills for self-respect
effectiveness, keeping one’s self-respect; the mnemonic here is FAST: (be)
Fair, (no) Apologies, Stick to values, (be) Truthful.
Applications of DBT
- Depression
- Bipolar disorder
- Anorexia Nervosa
(including restricting and binge-purge subtypes)
- Binge eating disorder
- Bulimia nervosa
- PTSD
- Substance use disorders
- Intellectual disability
or developmental disabilities
1. Who can benefit from DBT?
DBT is effective for
individuals struggling with borderline personality disorder, self-harm, suicidal
thoughts, eating disorders, depression, anxiety, and emotional dysregulation.
It is also beneficial for adolescents and adults facing interpersonal
difficulties.
2. What are the four core modules of DBT?
DBT is structured around
four modules: mindfulness, distress tolerance, emotion regulation, and
interpersonal effectiveness. Together, these skills help individuals achieve
balance, stability, and improved coping.
3. How is DBT different from CBT?
While CBT focuses on
changing negative thoughts and behaviors, DBT emphasizes acceptance and change
simultaneously. DBT integrates mindfulness and validation strategies, making it
particularly effective for managing intense emotions.
4. Is DBT effective for anxiety and depression?
Yes, research shows that
DBT can reduce symptoms of anxiety and depression by teaching clients to
tolerate distress, regulate emotions, and build coping mechanisms grounded in mindfulness
and acceptance.
5. Can I learn DBT skills on my own?
Yes, DBT skills can be
practiced through self-help books, apps, and online resources. However, working
with a trained DBT therapist provides guidance, accountability, and
personalized strategies.
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Website: www.emotionoflife.in
Email:
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