Dialectical Behavior Therapy (DBT) is a therapeutic approach combining elements of cognitive-behavioral therapy (CBT) with mindfulness and dialectics. Developed by Marsha Linehan, DBT was initially designed to treat individuals with borderline personality disorder (BPD). However, it has since been considered effective in addressing a range of other emotional and behavioural challenges.

At its core, DBT aims to help individuals build skills in managing intense emotions, improving interpersonal relationships, and fostering a greater sense of self-acceptance. The term “dialectical” refers to the balance between acceptance and change, emphasising the importance of acknowledging and validating one’s current experience while also working towards positive transformation.

The therapeutic model for DBT incorporates four main modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Mindfulness practices teach individuals to cultivate awareness of the present moment, while interpersonal effectiveness skills enhance communication and relationship-building. Emotion regulation strategies focus on understanding and managing intense emotions, and distress tolerance techniques help individuals cope with crises essentially without resorting to destructive behaviours.

DBT has gained recognition for its effectiveness in treating various mental health conditions, including depression, anxiety, and substance abuse and all are key areas of concern for counselling. The comprehensive and structured nature of DBT makes it a valuable tool for individuals seeking to navigate life’s challenges, develop resilience, and ultimately build a life worth living.

Dialectical Behavior Therapy (DBT) was first introduced by Linehan in the late 1980s. The foundational work on DBT began as Linehan worked on adapting traditional cognitive-behavioral therapy (CBT) techniques to better address the specific challenges faced by individuals with borderline personality disorder (BPD). This work laid the groundwork for subsequent research and the evolution of DBT as a comprehensive therapeutic approach. This article considers some of the key practices and ideas within DBT and their practical application and briefly examines the evidence from peer-reviewed literature.

Practices with DBT

Dialectical Behavior Therapy (DBT) incorporates several key practices aimed at helping individuals build skills to manage intense emotions, improve interpersonal relationships, and enhance overall well-being. Here are some key practices used within DBT

Mindfulness Skills:

  • Observing: Cultivating awareness of thoughts, feelings, and behaviours without judgment.
  • Describing: Using words to label and describe experiences without adding interpretations or judgments.
  • Participating: Fully engaging in the present moment, being involved in activities with full attention

Interpersonal Effectiveness:

  • Objective Effectiveness: Teaching individuals to be skilful in getting what they want in a specific situation.
  • Relationship Effectiveness: Focusing on maintaining and improving relationships by balancing priorities and considering the needs of both individuals.
  • Self-Respect Effectiveness: Emphasizing the importance of maintaining self-respect while achieving interpersonal goals.

Emotion Regulation:

  • Identifying and Labelling Emotions: Recognizing and putting words to emotions.
  • Opposite Action: Encouraging individuals to act opposite to their impulsive emotional urges.
  • Checking the Facts: Examining and challenging the accuracy of emotions in a given situation.

Distress Tolerance:

  • Distracting: Engaging in activities or thoughts that divert attention from distress.
  • Self-Soothing: Using comforting and nurturing activities to calm oneself.
  • Improving the Moment: Making positive changes to the current situation to cope with distress.

Validation:

  • Acknowledging and validating a person’s thoughts, emotions, and experiences, promoting a sense of acceptance.
  • Balancing validation with encouragement for change, creating a dialectical approach.

Dialectics:

  • Emphasising the integration of seemingly contradictory concepts, such as acceptance and change.
  • Balancing acceptance of oneself with the commitment to personal growth and positive change.

Diary Cards:

  • Keeping a daily record of emotions, behaviours, and skill usage to track progress and identify patterns.

Therapeutic Alliance:

  • Establishing a strong and collaborative relationship between the therapist and the individual, fostering trust and mutual respect.

These practices are usually integrated into a comprehensive and structured approach, allowing individuals to develop effective coping strategies for various situations. The combination of these skills addresses the dialectical tension between acceptance and change, which is a fundamental principle of DBT; a sort of balancing act between changing what we effectively can and accepting what we can’t change.

Practical example

A client, Doreen had suffered for years with difficulty in regulating her emotions and would often act impulsively, soothing her feelings with food and sometimes alcohol and was attending counselling for help with these behaviours. A key technique in DBT is to divert attention from the distress termed ‘distract’. Doreen incorporated going for a brisk 5-minute walk around the block and taking cold showers as a way of distracting from intense emotions and avoiding harmful behaviours while she waited for the impulse to pass.

Doreen’s approach comes from the concept of TIP,

  • TIP stands for Temperature, Intense Exercise, and Paced Breathing. These skills are designed to quickly change the body’s physiological response to distress.
  • Temperature involves activities like holding an ice pack or taking a cold shower. Intense Exercise encourages engaging in vigorous physical activity. Paced Breathing focuses on slow and controlled breathing to regulate arousal levels. In Doreen’s case she used the bathroom sink filled with cold water so she could immerse her face in the water for as long as she could comfortably manage for Temperature, the brisk walk for Intense exercise and opted to use square breathing (4 seconds in, hold for 4, 4 seconds out hold for four and repeat for 3 mins) and reported this back as highly effective in helping her impulses to binge on food or drink alcohol pass.

Besides the TIP skills Doreen used there are also a number of other helpful concepts within DBT:

Self-Soothing Techniques:

  • Self-soothing involves engaging in activities that provide comfort and calmness. This can include sensory experiences for instance taking a warm bath, or in a hot country floating in cold water/pool, listening to soothing music, using pleasant scents e.g. candles, or wrapping oneself in a comfy blanket.
  • The idea with self-soothing is to activate the parasympathetic nervous system, promoting relaxation and thereby reducing the intensity of any emotional distress

IMPROVE the Moment:

  • Another acronym is: IMPROVE, which suggests a number of strategies for improving the current moment when a client (or you!) is facing distress.
  • IMPROVE includes Imagery (imagining a safe and peaceful place), Meaning (finding meaning or purpose in the situation), Prayer (seeking support from a higher power), Relaxation (using deep breathing or progressive muscle relaxation), One thing in the moment (focusing on one thing at a time), Vacation (taking a mental break), and Encouragement (providing oneself with positive affirmations).

Pros and Cons:

  • Evaluating the pros and cons of acting on impulsive urges during distressing situations. This helps individuals make more informed decisions about their behavior and encourages a mindful approach to coping.

Evidence for DBT

DBT research has been ongoing for the last 35 years and work to date suggests effectiveness for treating borderline personality disorders (Linehan, 1993, Lynch, 2007, McMain et al,2009) Suicidality (Linehan et al, 2015) post traumatic stress (Bohus, 2013). More importantly for counselling DBT has also been found as a useful modality of treatment for Generalized Anxiety Disorder (GAD). Afshari and colleagues (2020) conducted a study which compared CBT to DBT and had 3 months post-treatment follow-up, the authors concluded:

‘the CBT group experienced greater reductions than the DBT group in symptoms of depression and anxiety, while the DBT group experienced greater improvements than the CBT group in emotion regulation and mindfulness. Findings seem to warrant the conclusion that, although CBT reduced symptoms of depression and anxiety more than DBT, DBT was more effective in improving emotion regulation and mindfulness than CBT’.

Yravaisi and colleagues (2021) conducted a study on 40, junior high school students using the well validated Beck anxiety inventory, the Beck depression inventory, the Problem Solving Styles Questionnaire and the Stress Anxiety and Depression Scale-42. They found that DBT significantly improved symptoms of depression, anxiety and stress compared to a control group. 

References

Afshari, B., & Hasani, J. (2020). Study of dialectical behavior therapy versus cognitive behavior therapy on emotion regulation and mindfulness in patients with generalized anxiety disorder. Journal of Contemporary Psychotherapy, 50(4), 305-312.

Bohus, M., Dyer, A. S., Priebe, K., Krüger, A., Kleindienst, N., Schmahl, C., … & Steil, R. (2013). Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: a randomised controlled trial. Psychotherapy and psychosomatics, 82(4), 221-233.

Linehan, M. M. (1987). Dialectical behavioral therapy: A cognitive behavioral approach to parasuicide. Journal of Personality disorders, 1(4), 328-333.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., … & Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized controlled trial and component analysis. JAMA psychiatry, 72(5), 475-482.

Lynch, T. R., Trost, W. T., Salsman, N., & Linehan, M. M. (2007). Dialectical behavior therapy for borderline personality disorder. Annual Review of Clinical Psychology, 3, 181-205.

McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman, L., & Streiner, D. L. (2009). A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry, 166(12), 1365-1374.

Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behaviour research and therapy, 48(9), 832-839.

Yravaisi, F., Mihandost, Z., & Mami, S. (2021). The effectiveness of dialectical behavioral therapy (DBT) on psychological components (stress, anxiety, depression) and problem solving styles in students with depression. Journal of Health Promotion Management, 10(1), 60-73.