DBT

Dialectical Behavior Therapy


DBT (Dialectical Behavior Therapy) was created by Dr. Marsha Linehan. It was initially created to treat people with Borderline Personality Disorder (BPD) with high incidents of suicidal and self harming behavior. People with BPD have a hard time with relationships and emotions. They have a constant fear of actual (or imagined) abandonment. A common phrase to think of related to people with BPD is "I hate you, please don't leave me". BPD (like other personality disorders) tend to be learned behaviors from childhood. There is no medication that can fix it. Enter in DBT... After using it with BPD clients, we learned it can help a wide array of individuals. I am more emotionally healthy when I teach DBT, than when I don't. (Not that I am unhealthy when I don't, it just have the skills more in the forefront of my mind if that makes sense)

Dr. Linehan is 77 years old, alive and well. Its kind of cool to be living in the same time as her, as many psychologists are from before our time! Anyway, when she was younger, she was diagnosed with schizophrenia. When she turned 18, and left the psychiatric facility she was living in, she no longer took medications. She had said she feels she has BPD. She developed DBT in the 1970s.

There are 4 parts of DBT. (1) Mindfulness (2) Interpersonal Effectiveness (3) Emotional Regulation (4) Distress Tolerance. Each of those parts have several skills. Mindfulness and Distress tolerance are acceptance modules. Interpersonal Effectiveness and Emotion regulation are change modules. Change and acceptance are the dialectics of DBT. Dr. Linehan asked what do you get when you mix black and white, while most people said grey, she said you get plaid. It's a good metaphor for changing and accepting. These are the most common skills we teach in group.


Mindfulness

In Mindfulness, there are 3 skills. (1) Wise Mind, (2) What Skills, (3) How Skills. In Wisemind we teach balancing between being too emotional, and too logical. The center is "Wisemind".(They use a venn diagram to visualize this) The "What Skills" are what we do to be mindful. We do 3 things 1-Observe, 2- Describe and 3- Participate. The How skills are how we do the what skills. We do those things (1) Non-Judgementally, (2) One Mindfully (meaning one thing at a time) and (3) Effectively (for example, what would a person strong in recovery do, or what is the most effective way to act and reach my goal).


Interpersonal Effectiveness

In interpersonal effectiveness, we teach how to deal with other people in a way that prevents manipulation, asserts your needs and allows you to keep your self respect. We use 3 primary skills. The acronyms are DEARMAN, GIVE and FAST. They stand for:

DEARMAN (Expressing needs, asking for something)

  • Describe one's situation using specific factual statements about a recent situation.

  • Express the emotions experienced when the situation occurred, why this is an issue and how one feels about it.

  • Assert one's self by asking clearly and specifically for what behavior change the person seeks.

  • Reinforce one's position by offering a positive consequence if one were to get what one wants.

  • Mindful of the situation by focusing on what one wants and disregard distractions through validation/empathy and redirecting back to the point.

  • Appear confident and assertive, even if one does not feel confident.

  • Negotiate with a hesitant person and come to a comfortable compromise on one's request

GIVE (Help maintain relationships, having difficult conversations)

  • Gentle: Use appropriate language, no verbal or physical attacks, no put downs, avoid sarcasm unless one is sure the person is alright with it, and be courteous and non-judgmental.

  • Interested: When the person one is speaking to is talking about something, act interested in what is being said. Maintain eye contact, ask questions, etc. Avoid the use of a cell phone during an in-person conversation.

  • Validate: Show understanding and sympathy of a person's situation. Validation can be shown through words, body language and/or facial expressions.

  • Easy Manner: Be calm and comfortable during conversation; use humor; smile.


FAST (keeping self respect, not being bullied)

  • Fair: Be fair to both oneself and the other person.

  • Apologies (few): Don't apologize more than once for what one has done ineffectively or for something that was ineffective.

  • Stick to One's Values: Stay true to what one believes in and stand by it. Don't allow others to encourage action against one's own values.

  • Truthful: Don't lie. Lying can only pile up and damage relationships and one's self-respect

Also, in interpersonal effectiveness, we review how firmly to say "no" and ways to do that.


Emotion Regulation


This module works on regulating emotions. We spend a lot of time describing emotions. Many DBT groups will do this in one session, I take a session to go through 1 or 2 emotions at a time (Emotion Regulation Handout 6 is 10 pages long and does a great job breaking them down, Emotion Regulation Handout 8A is a good one pager about when emotions are rightfully justified). So many of our participants are content with "happy, mad and sad" that they don't realize they are displaying anger, when it is really fear, or shame they are feeling, (This is why we removed "love" and "joy" from the diary cards. Our participants have this idea that negative emotions are "bad" so we would get diary cards with only "love" and "joy" marked. We give a place on the diary card to express gratitude, but we want them to be more comfortable identifying they are feeling others. After we review all the emotions, we look at 3 primary skills, (1) Check the Facts, (2) Opposite Action and (3) Problem Solving.


First we use Check the Facts to see if the emotion in of itself is justified. After doing so, we decide if it is effective to act on it. If it is not effective to act on it, we do the opposite (Emotion Regulation Handout 11 is 9 pages long and helps you figure out what opposite action is, and the difference between just doing it and doing it "all the way), if it is effective to act on it, we then problem solve. The format to problem solve in DBT (after checking the facts) is to

  • Identify the goal (what needs to happen to feel ok)

  • Brainstorm lots of solutions

  • Pick two solutions that look the best

  • Do a Pros and Cons list with the two solutions to narrow it down to 1

  • Create an Action Plan

  • Evaluate

Also, under Emotional Regulation we review skills to reduce emotional mind. The acronym for this is ABC PLEASE..

  • Accumulating Positive Emotions by doing things you enjoy (avoiding time wasters), identifying and focusing on your values so that you put your energy where you feel it is important

  • Build Mastery by getting a sense of accomplishment by doing something you are learning and getting better at

  • Cope Ahead by figuring out (when you are not emotional) how to deal in a situation that may come up and trigger emotions.

Finally, there is the PLEASE skill which stands for:

  • PhysicaL illness (treat) – If one is sick or injured, get proper treatment for it.

  • Eating (balanced) – Make sure of eating enough and feeling satisfied.

  • Avoid mood-altering drugs – Do not take other non-prescribed medication or drugs. They may be very harmful to the body, and can make moods unpredictable.

  • Sleep (balanced) – Do not sleep too much or too little. Eight hours of sleep is recommended per night for the average adult.

  • Exercise – Make sure to get an effective amount of exercise, as this will both improve body image and release endorphins making one happier


Distress Tolerance


Finally, distress tolerance is what it sounds like. Dealing with distress. It is different from emotion regulation because in distress tolerance, you aren't changing anything. You are just dealing with it and accepting it. There are several skills here.


Self Soothing

We help participants self sooth using each of the 5 senses.


Radical Acceptance

We focus on 4 parts, (1) Reality is what it is whether you like it or not (2) There are limitations in the future for EVERYONE (3) Everything has a cause, there isn't "for no reason" and (4) Life is worth living even with painful events. This goes further to discuss rejecting reality doesn't change it, and you have to accept it before you can change. Pain turns can't be avoided and when you refuse to accept something, you turn pain into suffering. While refusing to accept can keep you unhappy, and accepting can cause initial sadness, that sadness can turn into being calm. With Radical Acceptance we also talk about Turning the mind (your mind has a fork in the road, one side is rejection of reality, and the other is acceptance). We replace willfulness with willingness. (Willfulness meaning you don't have to be in control, it's not all about you and you don't have to fix every situation) Finally we talk about willing hands and half smiles, which essentially is faking it until you make it. Unclench your hands, open your palms, close your eyes and smile.


Mindfulness of Thoughts

This teaches "you are not your thoughts" and you can just observe your thoughts without acting on them.


Pros and Cons

We look at Pros and Cons list, but instead of it being a two part list (pro and con) it is a 4 part list. An example we use is changing jobs. You need to look at the Pro and Cons of changing the job, but also of not changing the job. I know they may sound the same, but take "Liking your supervisor". That is a pro of not changing jobs, but the con to changing jobs would be "not knowing who your supervisor is going to be". Depending on how much you like your supervisor and how much the unknown worries you, they can be weighted very differently.

Some acronym skills in Distress Tolerance are:


ACCEPTS

  • Activities – Use positive activities that one enjoys.

  • Contribute – Help others or the community.

  • Comparisons – Compare oneself either to people that are less fortunate or to how one used to be when in a worse state.

  • Emotions (other) – cause oneself to feel something different by provoking one's sense of humor or happiness with corresponding activities.

  • Push away – Put one's own situation on the back-burner for a while. Put something else temporarily first in one's mind.

  • Thoughts (other) – Force one's mind to think about something else.

  • Sensations (other) – Do something that has an intense feeling other than what one is feeling, like a cold shower or a spicy candy


IMPROVE

  • Imagery – Imagine relaxing scenes, things going well, or other things that are pleasing.

  • Meaning – Find some purpose or meaning in what one is feeling.

  • Prayer – Either pray to whomever one worships, or, if not religious, chant a personal mantra.

  • Relaxation – Relax muscles and breathe deeply; use with self-soothing.

  • One thing in the moment – Focus one's attention on what one is doing. Keep oneself in the present.

  • Vacation (brief) – Take a break from it all for a short period of time.

  • Encouragement – Cheerleading oneself, telling oneself that it is possible to make it through a situation and cope as it will assist resilience and reduce vulnerability


TIP skill

  • Tipping the temperature of one's face with very cold water. The idea is to bring on the diving relfex and bring the physiology down to slow it down. (This works really well if you can dip your entire head under water. That's not always possible, but your body automatically slows down your breathing when you're submersed.

  • Intense exercise of approximately 20 minutes.

  • Paced breathing as well as paired muscle relaxation.


STOP Skills

  • Stop (Literally, just stop everything you are doing, and pause before reacting)

  • Take a Step Back (Don't listen to your feelings, take a deep breath)

  • Observe (Not only what is going on outside of you, but also inside of you, for example: are you really angry or just hungry)

  • Proceed Mindfully (Which behaviors will make this better or worse)