Dialectical Behavioral Therapy

Dialectical Behavioral Therapy is a type of therapy that focuses on emotions. It is based on Cognitive Behavioral Therapy, but is adjusted for those who feel emotions very strongly. Cognitive behavioral therapy is based on the idea that a person’s negative behaviors stem from negative thoughts. Therefore, changing a person’s thoughts changes their behavior.

Those who experience extremely strong emotions, however, can find it invalidating to be told that their thoughts are in some way “wrong.” For this reason, dialectical behavioral therapy introduces the idea that a person can both learn to accept their unwelcome thoughts and seek to change them, hence the term “dialectical,” which means “combining opposite ideas.”

This type of therapy works well for those with borderline personality disorders, but anyone who experiences emotional dysregulation can benefit from it as well. It is also used to treat depression, anxiety, PTSD, eating disorders, and self-harm.

Dialectical Behavioral Therapy was developed in the 1980s by Marsha Linehan, an American psychologist.[1] It was originally utilized to help those who were suicidal and those with borderline personality disorders. It was created in a clinical setting, which means that it was first developed and practiced in the real world, not just in theory.

The core of dialectical behavior therapy resides in the combination of two opposing ideas: accepting oneself and changing oneself. One mantra common to those who practice and have gone through DBT is: “I’m doing the best that I can in this moment, and I want to and can do better.”[2] The “and” is key; both things are true at the same time and can be held in the mind at the same time.

DBT is focused on four key principles:

Mindfulness: the practice of living in the present moment.
Distress tolerance: the ability to manage emotional distress.
Emotional regulation: the capability to manage your emotions without letting them get out of hand.
Interpersonal effectiveness: the ability to communicate well with others.
Mindfulness

These four principles inform how a therapist guides their clients. When a patient practices mindfulness, they can block out distracting thoughts about the past or worries about the future and settle into the present moment. Often, this is done through breathing techniques or by naming things they can see, hear, smell, taste, and touch.

Distress Tolerance

The practice of mindfulness makes a person more able to tolerate distress. Often, mental distress is caused by cognitive distortions, where a person’s thinking does not reflect reality. These distortions can include things like catastrophizing, overgeneralization, shoulds, etc.

To tolerate this distress, therapists advise clients to dive deeper into their senses, becoming grounded as they reflect on the smells or textures around them. Distractions can also be helpful in learning to tolerate distress. The most difficult, but most important skill to practice, is radical acceptance, where a person learns to accept that things are not in their control.

Emotional Regulation

Radical acceptance can then lead to better emotional regulation, as you are able to recognize your feelings, name them, and decide how to deal with them, without being influenced by things outside yourself.

Interpersonal Effectiveness

Interpersonal effectiveness is the final core principle, which can be achieved when one is at peace with their emotions and thoughts. Interpersonal effectiveness is not just about listening well and being kind (although these are important things). Some aspects of interpersonal effectiveness also include setting boundaries, being assertive, and saying “no” when needed.

Since its inception in 1981, dialectical behavioral therapy has been widely used and studied. In 1981, Dr. Marsha Linehan showed that DBT was successful in treating women with suicidal tendencies and borderline personality disorder, which was thought impossible at the time. Since then, many studies have been done on different populations to test the effectiveness of DBT.[3]

In 1996, DBT was used to treat suicidal teens, and family therapy was added as part of the treatment plan. In 1998, DBT was shown to reduce self-mutilation behaviors and urges among women with borderline personality disorder, and in 2004, a study was conducted in which DBT was used to treat 14-17-year-olds with suicidal ideation. Those who received DBT treatment “had significantly fewer behavioral incidents and problems on the ward. There were no completed suicides in either group, and both groups demonstrated highly significant reductions in parasuicidal behavior, depressive symptoms, and suicidal ideation at 1 year.”

Because of its emphasis on validation, in addition to its encouragement for change, dialectical behavior therapy is an extremely useful and effective tool for those whose negative or distorted thoughts or emotions result in negative and destructive behaviors.

Before beginning dialectical behavioral therapy, the therapist will ask the client to complete a pre-assessment to make sure DBT is a useful form of therapy for that person.

Once that is determined, DBT is usually practiced in one-on-one sessions, but weekly group sessions are often a part of therapy as well. The therapist might, at the beginning of therapy, be available by phone or text outside of the initial individual sessions to help coach a patient through specific situations.

During the session, the therapist teaches the patient about the core principles mentioned above and the skills that allow the patient to practice those principles. Often, the therapist will assign “homework” that allows the patient to practice those principles and strategies in their life. Patients can keep a diary or log to track how they have used those skills between sessions.