Dialectical Behaviour Therapy

Dialectical Behaviour Therapy is a talk therapy that supports people who experience intense and fluctuating emotions (sometimes called emotion dysregulation). It was developed in the 1980s when behaviour therapist Marsha Linehan found that her clients 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 biosocial theory, mindfulness, dialectics, and principles 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 encourages people to accept themselves the way they are, with compassion for the pressures and circumstances that led them to where they are now. Often the most hopeless or destructive decisions are made in an attempt to survive. But this self-acceptance is also matched with a push towards change, so that the person doesn’t stay stuck in pain
• 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 find it hard to take the steps to get the life they want due to not knowing how, reluctance to give up ways of coping that have helped in the past, 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 still taking steps towards change (being mindful that not changing will be more painful in the long run)
• Being capable and asking for help - DBT recognises 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 the process of change, 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
• Need to be gentle with yourself and tougher on yourself - DBT recognises that people who feel stuck often hold on to ways of coping that once helped (being too gentle), while being very harsh and judgemental towards themselves (being too tough). The dialectic here is being able to recognise when certain coping strategies are no longer working for you and need to 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).

Acceptance

A key principle 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 painful

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

Validation

Another key principle of DBT is incorporating validation. DBT holds that all feelings deserve to be acknowledged as:

1. Real - uncomfortable feelings are still there despite our attempts to suppress them
2. Important - if we ignore uncomfortable feelings they eventually find a way of coming out, such as through unhelpful ways of coping
3. Making sense - even emotional responses that seem out of proportion make sense if we have all the contextual information. Sometimes we need to look at a person’s past for an emotional response to a particular situation to make sense

Another dialectic here is balancing validation and change. It is hard to work towards change if we do not accept and validate our feelings first, as we will only see a problem worth working on if we 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-judgemental 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 (for example, by turning to unhelpful ways of coping). Once the intensity of difficult feelings subsides, we are then in a much better place to deal with things effectively.

3. Emotion Regulation

While distress tolerance skills can provide immediate benefit, emotion regulation skills involve strategies that reduce emotional pain in the long term.

4. Interpersonal Effectiveness

Interpersonal effectiveness skills (relationship and communication skills) cover strategies to communicate with others effectively, e.g. how to make a request while keeping the other person liking you.

What can DBT help with?

Marsha and her colleagues initially developed DBT for women with a diagnosis of Borderline Personality Disorder who were living with ongoing suicidal thoughts. It has since been shown to help with:

• Depression
• Intense emotional states
• PTSD and cPTSD
• Eating disorders
• Alcohol and other drug use
• Self-harm
• Acting on impulse, such as overspending, shoplifting, dangerous driving etc.

Is DBT a group therapy?

Yes. DBT was designed to take the form of a 6-12 month program that includes weekly 2.5-hour skills training in a group setting, weekly 1-hour individual sessions, and between-session phone coaching. 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.