What is DBT?
Background on DBT
Dialectical Behaviour Therapy (DBT) is a type of therapy developed by the psychologist Dr. Marsha Linehan in the early 1990’s in response to her recognition that traditional forms of therapy at the time, were not meeting the needs of some of her clients who lives were in “literal hell” with deep suffering. Many of her clients could not envision their life as life worth living and were engaging in suicide attempts and other life threatening behaviours such as self-harm, eating disorders, high-risk substance use, high-risk sexual behaviours, and destructive and/or chaotic interpersonal relationships amongst other behaviours. Dr. Linehan developed a form of therapy that built upon the traditional cognitive behavioural therapy (CBT) available at the time, and still widely used, and incorporated many Eastern influenced Zen based practices such that the new DBT therapy embodied a flexible treatment intervention that changed as the client progressed with a focus on both acceptance and change.
Dr. Linehan described the core of the treatment as “… the application of problem-solving strategies” otherwise known as change strategies with “validation strategies” (Linehan, 1993) otherwise known as acceptance strategies. This exquisite “teeter-totter” of treatment described by Dr. Linehan has now withstood thousands of research studies (of the highest scientific rigour) across the globe in countless contexts. From children through to seniors, school based through to hospital based and community based settings, clients with a range of mental health struggles (not limited to Borderline Personality Disorder as the model originally conceptualized), and from clients through to healthcare workers, parents, teachers, and other parties interested in learning sound skills to improve communication, increase emotional regulation in the workplace, tolerate distress more effectively when crises arose, and practice mindfulness to respond from a wise minded place vs. reacting.
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Let’s hear from Dr. Linehan as to how everyone can benefit from learning the skills
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As was originally researched and conceptualized, DBT at its core has four differing skill set modules (and five if working with adolescents). Each of these modules attends to the core teeter totter of acceptance and change. Let’s look at each of these in the next section.
What are the Four Core Modules within DBT?
The four core modules within DBT include Mindfulness, Interpersonal Effectiveness, Emotion Regulation and Distress Tolerance. As was named in the section describing ‘What is DBT?’, each of these modules attends to teaching either acceptance-based strategies or change based strategies on the teeter-totter of standard DBT.
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Image at left: @clarifycounseling.com
Before we watch Dr Linehan describe the modules in the following 4 videos, let’s give a brief overview of each one:
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Mindfulness is a well used word in today’s culture, but what does it really mean? Often interchanged with meditation, mindfulness, as a practice, is actually much broader. As a practice, mindfulness helps us to “see clearly so we can make wise minded choices and respond to life more effectively” (Shapiro, 2020). The skills within this module teach us what to do to be mindful and how to do those practices.
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Interpersonal Effectiveness is in essence how to do and be in relationships more effectively. Skills taught within this module focus on assertiveness, behavioural reinforcement, and more effective empathy and validation skills that can be applied both to oneself or others.
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Emotion Regulation teaches the skills needed to know how to regulate one’s feelings and urges so that the most wise minded choices can be made. As is often noted, it is very hard to get our needs truly met when we cannot accurately express to another (or even to ourselves) what we are feeling, how we are feeling that emotion, how intensely we are feeling an emotion or sensation, and what we can do to even out (i.e. regulate) the intensity of that emotion so that we need not escape it or try to “problem solve” the emotion through maladaptive means. This module teaches each of these facets in more effectively learning how to regulate our emotion(s).
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Distress Tolerance is the learning involved in tolerating a crisis without making it worse. As clients learn, we always have five choices in solving a problem – and in distress tolerance, we aim to help clients choose choices that both at a minimum do not leave them feeling more miserable or make the situation worse. Skills are taught in the art of learning how to tolerate distress, how to shift attentional focus, how to self-soothe and how to change our physiology as a means of bringing our ‘executive functioning’ part of brain back online from our emotion warehouse (i.e. amygdala).
Emotion Regulation Video
https://youtu.be/lXFYV8L3sHQ?si=PpOpN4qLjTE4nbFk
Mindfulness Video
https://youtu.be/PCJ0R6vAUnw?si=OjjGEnvg598cssuJ
Distress Tolerance
https://youtu.be/sJrgPC11VS0?si=VxSHbybJEPYCR5pc
Interpersonal Effectiveness
What is the “D” in DBT? The art of Dialectics
Dialectics (the D in DBT) is the process of holding and searching for multiple perspectives to the same situation; with the core question in the search being “what information am I missing… what is being left out of my understanding?” This process of bringing together seemingly opposite perspectives allows us to move away from polarized thinking; the very kind of thinking that tends to increase intensity of emotions and lean us towards rigid behavioural choices.
To do this, we look at two things that are opposites and consider how both might be true at the same time; specifically we bring together two statements that are normally joined with a “BUT” and replace it with an “AND”. As an example, a core assumption in DBT is that people are doing the best they can AND they can try harder and do better. Look at how different that statement lands when we replace the AND with a BUT – people are doing the best they can BUT they need to try harder and do better. Do you notice yourself polarizing to the last half of the sentence? The try harder? Do you notice thoughts about how someone just needs to try harder? This change of just one word closes down our thinking and leaves us vulnerable to the emotion that then comes with the thoughts of why someone is not trying harder and why can’t they just do the behaviours to try harder?
So, dialectics broaden our curiosity, invite us to hold what does it mean if two things are true, and then how can we choose our response based on the ‘both’ being true. Which ultimately is a growing of our knowledge and perspective.