DBT: Dialectical Behavior Therapy


Dialectical Behavior Therapy (DBT) was developed for people with borderline personality disorder (BPD). It combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT has been clinically proven to be effective in treating BPD as well and those who have symptoms and behaviors associated with mood disorders, self-injury (e.g. cutting), sexual abuse, and chemical dependency. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, particularly those found in romantic, family and friend relationships. Some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels. While I don’t work with those with BPD, I do use a modified, body-centered DBT approach with people who suffer from emotional intensity and mood swings.

Characteristics of DBT

  • Support-oriented: It helps people identify their strengths and builds on them so that they can feel better about themselves and their life.
  • Cognitive-based: DBT helps people identify thoughts, beliefs, and assumptions that make life harder such as, “I have to be perfect at everything,” or  “If I get angry, I’m a terrible person.” It helps people to learn different ways of thinking that will make life more bearable, such as  “I don’t need to be perfect at things for people to care about me,” or  “Anger is normal emotion and everyone gets angry.”
  • Collaborative: It requires attention to the relationships between client and counselor. In DBT, people are encouraged to work out problems in their relationships with their counselor and the counselor does the same with them. DBT asks people to complete homework assignments, to role-play new ways of interacting with others, and to practice skills such as soothing yourself when upset. These skills are a crucial part of DBT.
  • Individual weekly psychotherapy sessions: Sessions emphasize problem-solving behavior for the past week’s issues and troubles that arose in the person’s life. Self-injurious and suicidal behaviors take first priority, followed by behaviors that may interfere with the counseling process. Quality of life issues and working toward improving life in general may also be discussed. DBT sessions also focus on decreasing and dealing with post-traumatic stress responses and helping enhance their own self-respect and self-image.

The Four Modules of Dialectical Behavior Therapy:

  1. Mindfulness.  The core mindfulnesswhat” skills are:  Observe, Describe, and Participate. They answer the question, “What do I do to practice core mindfulness skills?” The core “how” skills are:  Non-judgmentally, One-mindfully, and Effectively. They answer the question, “How do I practice core mindfulness skills?”
  2. Interpersonal Effectiveness. Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict. The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.
  3. Distress Tolerance.  Most approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. DBT understands that we cannot always change our external circumstances, but we do have the power to changer our internal reactions. Therefore, DBT emphasizes learning to bear pain skillfully, while also understanding that acceptance of reality is not approval of reality. Crisis survival strategies taught: distracting, self-soothing, improving the moment, and thinking of pros and cons.  Acceptance skills taught include: radical acceptance, turning the mind toward acceptance, and willingness versus willfulness.
  4. Emotion Regulation.  Emotional Regulation skills include: Identifying and labeling emotions,  Identifying obstacles to changing emotions, Reducing vulnerability to “emotion mind”,  Increasing positive emotional events,  Increasing mindfulness to current emotions, Taking opposite action, and Applying distress tolerance techniques