DBT 101: Dialectical Behavior Therapy Basics – What is It? How Does It Work?
When you’ve been troubled by the same problems for years, and previous therapy hasn’t been very helpful, don’t give up hope. It might just be time to consider a new form of treatment. Dialectical behavioral therapy, or DBT, is a form of therapy developed by Dr. Marsha Linehan. If you’re not familiar with dialectical behavior therapy and you haven’t yet seen benefits from counseling, it’s worth exploring.
Here are the basics about this treatment from therapists that use it daily.
What is DBT?
Dialectical behavior therapy, or DBT, is a form of comprehensive cognitive-behavioral therapy. It was initially developed to treat patients with chronic suicidal thoughts, particularly as a part of borderline personality disorder. The suicidal thoughts occurred less frequently when patients learned how to manage and redirect their thought patterns.
Therapists have been using DBT with their patients since the 1970s, even here in Houston.
We know today that the techniques of DBT can be very beneficial for many people than it was created for, especially those who haven’t responded well to therapy or medication. DBT can help people who struggle with various issues, including eating disorders, issues with self-harm, addiction, and post-traumatic stress.
What Does DBT Mean?
Dialectical – refers to two things that seem contradictory or opposite but are both true. An excellent example of this would be the belief that people are doing the best they can AND, yet, they need to try harder. We are always trying to facilitate balance and find acceptance – you’re doing the best you can right now.
There are always different things you can try to get the life you want. Change is achievable and is often for the better.
Behavior – you and your counselor will work to understand established target behaviors. These consist of things you are working to increase or decrease to make your life better. What these are and how much you want to add or relieve yourself of depends on you and your behaviors.
An example of this would be thinking about suicide or a lack of self-care in your daily routine.
What Is DBT Used For?
Although you may not have caused these problems, you have to solve them for yourself. This means there is a focus on learning skills to live the life you want versus blaming others for what is wrong.
Dialectical behavioral therapy focuses on what happens before and after a target behavior.
In DBT, dialectical strategies help clients detach themselves from extreme positions. Dialectics, which means logic through conversation, is the way we balance acceptance and change. It allows the client to sort out issues one conversation at a time.
It’s how we can look at two ideas that seem contradictory as related. You know what is true about your position because you love your perspective. It’s what you understand. What’s difficult is figuring out what is correct in another person’s situation, allowing us to have the whole truth or a synthesis.
After all, people in a lot of emotional pain get stuck between wanting to embrace life and feel they can’t tolerate anything, finding themselves frustrated about what life may bring.
You and your therapist will work towards the goals that you define. Your therapist will be focused on helping you build YOUR life to be something worth living. DBT is most helpful with people who have powerful emotions or take extreme positions.
Clients can even reach out to their therapist for in-between session coaching when clients need help in crises.
How does DBT work? What is the process?
There are two primary components to this process:
The first is individual therapy, in which you explore your personal feelings, situation, and goals. In individual therapy, you will explore ways to get new behaviors to occur based on the goals you’ve set. Clients and therapists work as a team in these individual sessions, focusing on learning and improving social and coping skills.
Previous to treatment, we will commit to goals the client is looking to achieve. When treatment begins, your counselor will attend to any life-threatening behavior. If that is addressed, we work on motivation and increase behavioral skills to replace the ones that aren’t working.
The next stages involve working on value-driven goals that may be slower to change, such as developing positive and lasting relationships, finding ways to make meaningful contributions to others, and achieving financial stability.
DBT was primarily developed to manage overwhelming emotions. People that experience overwhelming emotions might feel that the knob is turned way up that shows up in a big wave, whether they are feeling angry, sad, or scared. In DBT, problems arise from the difficulty of managing painful emotions.
Trying to stop your feelings doesn’t work and never has. If the waves are the strong emotions crashing against your boat, how do you learn to be the captain of your ship? We must learn to work with the waves rather than against them.
DBT assumes that many of the problems exhibited by clients are caused by skills deficits, meaning they merely lack the skills for handling such powerful emotions. This usually results in someone using less helpful behaviors to cope with overwhelming or painful thoughts and feelings simply because they don’t know what else to do.
For example, suicidal and self-harming behaviors are often used to cope with painful thoughts and emotions about past trauma. The goal is for clients to use these skills to prevent suicide urges from increasing and to not act on suicidal impulses when they are present.
DBT works by helping clients better understand the factors contributing to suicidal and self-injurious behaviors and identifying and using more adaptive problem-solving strategies.
For example, clients learn DBT skills that can help them tolerate urges to engage in these behaviors, reduce painful emotions without resorting to life-threatening behaviors, and improve difficult relationships that may contribute to suicide risk.
What Makes DBT Helpful?
It breaks things down into steps, so it’s easy to follow through difficult moments. For example, when you experience a build-up of intense emotions, you will have a roadmap of strategies to help you handle these feelings and redirect them in a positive, even productive way.
Additionally, DBT focuses on becoming more skillful in the context of validation and understanding that you are doing the best you can as well as using dialectics to cultivate confidence in that truth.
Your therapist will work to shift the focus from the past to here and now. We ask ourselves questions like how can we handle this crisis now? How can you cope right now?
Rather than concentrating on the past or using blame or judgment, the focus remains on problem-solving and making life better now, something trudging up the past or judging rarely allows.
Have you ever heard of them? It’s an exercise used in DBT to help identify potential triggers and work on avoiding said triggers. You track your experiences throughout the day in a journal or notebook and bring these notes with you to your therapy sessions.
This can also help you develop coping skills to handle triggers better that may be unavoidable.
This kind of routine monitoring is critical to enable therapists to intervene when suicide urges are high and assess the factors that lead to increases and decreases in suicidal impulses over time.
DBT Primary Modes of Treatment
Clients receive group skills training, individual therapy, and coaching from their personal therapists between sessions. Group training is used to learn the DBT skills of mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.
Whereas individual therapy is focused on applying the skills and strategies of DBT to help them achieve their specific treatment goals. As an additional resource, coaching is helpful when they need help using DBT skills for crisis situations.
Skills training in a group format:
Dialectical behavior therapy teaches four critically essential skills that can reduce the size of emotional waves and help you keep your balance when those emotions overwhelm you.
Goals of DBT
The main goal of DBT is to help you build a life worth living. This means having things that are meaningful and important to you in your life.
DBT helps you to work with your thoughts, emotions, and behaviors differently from how you may have in the past, and that incorporates your values and what is most meaningful to you.
There is hope if you are suicidal – it’s one way to overcome these feelings. So the focus is on building skills and responses to difficult emotions and behaviors that support skillful coping.
Who is DBT helpful for?
It is particularly useful for people who have out-of-control behaviors and emotions, especially suicidal urges, self-harm behavior, substance abuse, anger, and interpersonal difficulties. It is uniquely good at helping with (suicidal or self-harm behavior) the more problematic behaviors that arise when coping with difficult emotions.
An example would be if you feel like your life is an emotional roller coaster. You might feel like you get more disappointed than others; cry at movies, or feel different from others.
If one or more of these sounds like you, DBT might be a good fit for you. Clients struggle with difficulty regulating their emotions. It focuses on feelings themselves, so it has broad applicability.
How does this develop?
There can be many paths that lead to emotional pain – whether it be genetics, environment, or traumatic experiences. When we experience trauma at critical points in our development, it can alter our brain structure to make us more vulnerable to intense, negative emotions.
What are the DBT Skills? 4 Basic Skills
Dialectical = two opposite ideas can be true simultaneously, and when considered together, they can create a new truth and a new way of viewing the situation. Dialectical strategies are a way to get moving when you are stuck.
There is always more than one way to look at a situation. DBT teaches four primary skills to help people manage their thoughts. These skills include the following:
1. Core mindfulness skills – how to practice staying focused on the present moment. This is important because if you need to know what’s going on in the moment and recognize that you’re in distress, you can respond effectively. Many people with chronic depression or unstable moods worry about things in the past or future. Mindfulness trains your brain to stay in the here and now.
2. Emotional regulation skills – how to identify and label what you’re feeling and then increase positive emotions. We know about how emotions work because the more we try to suppress them, the bigger they get. Emotion regulation teaches you how to change feelings that you want to change, like angry outbursts or crying in response to minor frustrations.
3. Distress tolerance skills – these help you identify what to do when you have urges to hurt yourself, fight with your partner, etc. These tools are designed to help you get through the crisis at the moment. This teaches you to learn to tolerate mildly to moderately unpleasant experiences along with the pain and suffering that is inevitable to the human condition.
The distress tolerance module is split into four crisis survival strategies:
- Improving the moment
- Thinking of pros and cons
4. Interpersonal effectiveness skills – navigating our relationship with ourselves and others to bring about balance. These allow us to find a balance between our priorities versus our life’s demands. They enable you to ask for the things you want while also saying no to things you don’t want. DBT teaches you how to advocate for your likes and dislikes in a way that creates respect for yourself and others.
What Do You Do with Those Skills?
Once you have learned the necessary skills of DBT, that’s when the therapist teaches you how to put them into practical use. The DBT skills are divided into two categories:
- Acceptance – mindfulness and distress tolerance
- Change – interpersonal effectiveness and emotion regulation
The goal of DBT is to find a healthy balance of these four components, so you learn how to weather the storms of life with more ease.
Most people who pursue DBT have more than one problem they need to address. Like Alexandra in our practice, a therapist will help you put together the skills you learned in DBT. You will learn how to apply the skills in situations like relationship conflict, creating a structured environment, and gaining motivation to set and pursue goals.
Stages of DBT
There’s a lot more to the process than just learning the basic skills of DBT. Generally, most DBT therapists follow a series of steps that may include the following:
- Stage 1: Many patients begin therapy in a state of crisis, so it’s first important to help them stabilize and establish an atmosphere of safety and calm. This starts with teaching patients how to gain some control over their emotions in the short term.
- Stage 2: Most patients have more stable behavior in this stage, but emotional reactions can still cause occasional trouble. The therapist helps the patient to safely explore the causes of emotional pain instead of burying it.
- Stage 3: This stage focuses on the maintenance of healthy behavior and reasonable goal-setting. In this phase, you focus on pursuing happiness and stability.
- Stage 4: In this phase, you focus more on big-picture goals. You determine the goals you want to achieve and make plans to go after them. The focus is not only on maintaining happiness and stability but also on pursuing spiritual fulfillment.
What do you do when you have an overwhelming urge to kill yourself?
First, elicit the mammalian dive reflex using cold water. Splash your face in ice water or cold water, or get in a cold shower. This impacts the vagus nerve that runs in our body – it works as a reset button restarting your computer. This action resets your intense emotions and brings them down a peg. When you bring it down, you can think more clearly, and the world looks different.
***If you are very calm already and NOT emotionally intense, the best step to take is to go to sleep and wait.***
After bringing down your emotional arousal, don’t make any critical decisions.
Ultimately, you’ll want to go and find anyone and make eye contact with them whether it be on messenger, a clerk in a store, etc. This helps us get out of our heads.
You learn this ahead of time so you can apply it in moments of stress.
Be Mindful of Current Emotions
The most difficult and helpful skills to learn. It’s a practice of getting to know your body better and find out what’s happening.
Emotions are happening IN our bodies. When we turn our attention to what is happening in our body and experiencing can actually CHANGE emotion. Daniel Siegel refers to this as “name it to tame it.”
You might not solve the problem, but the intense emotion always passes. Feelings come and go like waves. Once you’ve learned this skill, it’s useful to use in a crisis.
Also, try paced breathing to as getting out of your head. With each breath, make your exhale longer than your inhale.
Non-Demand Caring Contacts
Suppose you know that there is someone in your life dealing with these types of difficult positions. When people receive caring contact, it heavily reduces the risk of suicide: just a text message, an email with no demands, no judgment.
I’m thinking of you. I am caring about you.
“Just I’m thinking of you.” It’s about human connection and will help people from falling through the cracks. Just pull out your phone now and send it to someone you care about.
Participate in Our DBT Therapy and Skills Groups
We offer groups for adults and teens who are looking to learn effective coping skills for overwhelming emotions. These groups are designed to help you cultivate and improve the quality of your interpersonal relationships.
For adults, we work towards developing the four basic skills of DBT in a context that supports you while you take control back from those extreme feelings and positions that limit you.
For teens, the group helps them with the same things, but within the context of their age. The group will focus on making choices to develop a life that they love and will be proud of.
***Due to the COVID-19 pandemic these groups are being held online until further notice.
Consider Dialectical BehaviorTherapy
Life in Houston has so much to offer. Set yourself free from the things that have troubled you in the past so that you can be free to enjoy life. Consider the possibilities of DBT.
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