Dialectical Behaviour Therapy

Dialectical Behaviour Therapy is a talk therapy that aims to treat emotion dysregulation (intense and fluctuating emotions). It was developed in the 1980s when behaviour therapist Marsha Linehan found that her patients were not responding to Cognitive Behaviour Therapy (CBT) and reported that they found it invalidating.

Marsha took the foundations of CBT and incorporated other concepts such as the biopsychosocial theory (see the biopsychosocial model), mindfulness, dialectics, and principals of acceptance and validation.

Dialectics

Dialectical means two opposing things being true at the same time. DBT argues that people (and situations) are complex, and often opposing facts can both be true. DBT involves “walking the middle path”, which means finding the middle ground between both extremes.

Some common dialectical conflicts:

• Self-acceptance versus change - DBT argues that the patient needs to accept themselves the way they are, being compassionate to the pressures and circumstances that led to the patient being in the situation they are in. Often the most hopeless or destructive decisions are made in an attempt to survive. But this self-acceptance needs to also be matched with a push towards change so that the patient does not stay stuck in suffering
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• Wanting a different life while resisting change - Often people find themselves in a situation in which they desperately want things to be better, and yet find themselves actively resisting change. Others can interpret this resistance to indicate that the person doesn’t want to get better, but DBT argues that this is not necessarily the case. People can want a different life, but may struggle to take the steps to get the life they want due to not knowing how, reluctance to give up unhealthy coping strategies, feeling incapable or anxious about the process, fear of failure etc. Finding the middle ground here involves openly acknowledging and exploring resistance to change, while nevertheless taking steps to recover (being mindful that not changing will be more painful in the long run)
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• Being capable and asking for help - DBT recognise a tendency for people to slide into fierce independence, or hopeless passivity (or a mixture of the two). The middle ground in this dialectic involves on the one hand taking ownership of recovery, while on the other hand knowing when you need to ask for help and taking that help when it is effective and wise to do so
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• Need to be gentle with yourself and tougher on yourself - DBT recognises that patients that feel stuck have a tendency to defend or protect dysfunctional coping strategies (being too gentle), while being extremely punitive and judgmental towards themselves (being too tough). The dialectic here is being able to recognise when certain coping strategies are no longer working for you and require change now even if change is painful (getting tougher), while incorporating compassion and understanding that change is hard and refusing to blame yourself for having gotten stuck (getting gentler).
  

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Acceptance

A key principal of DBT is adopting an accepting attitude, rather than denial. An accepting attitude acknowledges:

• Accepting yourself for who you are
• Accepting your situation/problem for what it is
• Accepting others for who they are
• Accepting the world as it is - one which can be unfair and full of suffering

DBT argues that in accepting things as they are, energy can then be devoted to things that can be changed. This is another DBT dialectic - balancing acceptance and change. This concept is similar to the serenity prayer:

Grant us the serenity to accept the things I cannot change
Courage to change the things I can
And the wisdom to know the difference

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Validation

Another key principal of DBT is incorporating validation. DBT argues that all feelings must be acknowledged as:

1. Real - uncomfortable feelings are very real despite our attempts to suppress them
2. Important - if we ignore uncomfortable feelings they eventually find a way of coming out, such as through unhealthy coping strategies
3. Making sense - even the most seemingly ridiculous emotional response makes sense if we have all the contextual information. Sometimes we need to investigate a persons past for an emotional response to a particular situation to really make sense

Another dialectic here is balancing validation and change. Individuals cannot work towards change if they do not accept and validate their feelings first, as you will  only see a problem worth working on if you acknowledge it as valid first

DBT skills fall under four main categories:

1. Mindfulness‍

Mindfulness refers to the skill of bringing your thoughts back to the present moment. Rather than have our worries dictate what we are thinking about, mindfulness practice allows us to choose how we direct our attention.
DBT places emphasis on developing non-judgmental awareness of our thoughts and feelings - not judging our thoughts and feelings as good/bad, right/wrong, just accepting them as they are.‍

2. Distress Tolerance

Distress tolerance skills involve strategies to navigate intense emotional states to help people get through a crisis without making things worse i.e. engage in unhealthy coping strategies. Once the intensity of difficult feelings subside, we are then in a much better place to deal with things effectively.

3. Emotion Regulation

While distress tolerance skills provide can immediate immediate benefit, emotion regulation skills involves implementing strategies that reduce emotional suffering in the long-term.

4. Interpersonal Effectiveness

Interpersonal effectiveness skills (relationship and communication skills) covers strategies to communicate with others effectively eg. How to make a request while keeping the other person liking you.

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What can DBT help with?

Marsha and her colleagues initially developed DBT for women with Borderline Personality Disorder and chronic suicidal ideation. It has since shown to be effective for:

• Depression
• Anxiety
• Intense emotional states
• PTSD and cPTSD
• Eating disorders
• Addiction
• Self-harm
• Impulsive behaviours including excessive spending, shoplifting, dangerous driving etc.
  

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Is DBT a group therapy?

Yes. DBT was designed to take the form of a 6-12 month program that includes weekly 2.5 skills training in a group setting, weekly 1 hour individual sessions, and a 24 hour crisis telephone counselling. We do not offer group therapy at Exhale Psychology Centre, but can offer individual DBT skills training. You and your therapist can work together to discuss if group therapy might be needed.