Dialectical Behavior Therapy

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.

Diary Cards

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.

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.

It’s not a suicide prevention program.

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. 

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.

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:

How to practice staying focused on the present moment.

This is important because you need to know what’s going on in the moment and recognize that you’re in distress, so 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.

Emotionally vulnerable people often experience emotions in a more intense manner. Do you have a hard time returning to a stable feeling once upset? Mindfulness skills can help.

Through a meditative process, you’ll learn to slow down your thoughts and notice them without judgment or actively trying to control them.  You simply access your thoughts and accept them as they are. This helps alleviate the tendency to act impulsively or rashly.

As the goal in mindfulness is to remain open and aware of your internal thoughts, feelings, triggers, and responses, you also learn to stay present and engaged. Thereby, you are less inclined to feel overcome by worry and upset.

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.

Emotion regulation skills address emotional vulnerability directly. It is, essentially, the skills associated with regulating out-of-control states of emotion. This approach can affect positive change over time while giving you immediate tools for coping with overwhelm when it happens.

Emotional regulation skill sets include the following tools:

Opposite action skill

Your body and emotions are linked inexorably. What happens to you emotionally inspires a somatic, or bodily, response.  For example, if you’re feeling sadness you may naturally withdraw from other people. If you follow the idea of opposite action, you would decide instead to pursue time with friends or meet up with coworkers. Behaving in a manner opposite of your usual action facilitates actual change in your emotions.

Checking the facts DBT Skill 

This skill is built upon a bit of investigative work. You’ll practice asking questions like, “What happened to trigger my emotion?” and “ What assumptions did I make about the event to cause my overreaction?”

This will help you check the facts as an event is happening and give you a way to dial back the intensity of those extreme emotional waves.

P.L.E.A.S.E. — PLEASE Mastery, a DBT technique

Centered on tempering emotional vulnerability through intentional maintenance of a balanced lifestyle. PLEASE is an acronym that serves as a reminder of how to take care of yourself and avoid susceptibility emotional outbursts.

PL: Physical illness

E: Eat in a balanced way

A: Avoid mood-altering substances

S: Sleep well

E: Exercise

Focus on positive events

The goal is to learn to pay attention to what is good, edifying, and positive. Practice will help you avoid rumination and concentration on what exacerbates negative emotion overwhelms you.

These skills 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:

• Distracting
• Self-soothing
• Improving the moment
• Thinking of pros and cons

Distress Tolerance is about coping well in a crisis. You can learn to skip the emotional outbursts, impulsive overreactions, and that stuck feeling that is so difficult to overcome.

What is Distress Tolerance?

In many therapeutic approaches, distressing events are seen as the problem. They are why the sessions started in the first place. Therefore, distress is something to be managed or, if possible, removed from one’s life. However, of course, pain and discomfort are both normal and inevitable.

From this realization, DBT has other plans for distress. You and your DBT therapist work diligently toward three goals:

• Accepting distress
• Finding meaning in your distress
• Tolerating distress

Distress tolerance skills are varied and numerous. All of these DBT skills grow progressively from a foundation of the above-mentioned mindfulness. A couple will be touched upon in the sections below.

In your current situation, you can accept without automatically judging whatever is causing you to suffer. You’re not accepting it in an approving way and you likely want things to change. More accurately, you could say DBT distress tolerance skills enable you to accept reality. This puts you in a position to make more pro-active and productive choices.

DBT techniques for distress tolerance include the following:

Cold Water:

This is exactly what it sounds like. If you immerse your face under very cold water for 15 to 30 seconds, it will trigger the “dive response” in your brain just as you are about to react to an extreme or emotional situation. Your heart rate will decrease and blood will be redirected to the heart and brain.

As you might imagine, this process can effectively de-escalate many distressful emotions. Literally, cooler heads will prevail.

The STOP Skill:

S = Stop: Remain still and resist reacting. Choose to control your body.

T = Take a Step Back: To avoid acting impulsively, remove yourself from the situation and focus on your breathing.

O = Observe: Detach, take in your surroundings, and focus on what you are feeling.

P = Proceed Mindfully: Remind yourself of what your goals are and how to best achieve them under the circumstances.

Radical Acceptance:

Some things are out of our control. Your emotional vulnerability may lead you to ruminate on the thought that you shouldn’t be in a situation or that it is inherently unfair to you. Radical acceptance is a healthier way to think about the situation. Learning to accept the problem as it is and not focus on how it should be different promotes less anxiety, anger, and eventual overwhelm.

Self-Soothe

DBT advocates self-soothing with your five senses. Try to engage your five senses to mitigate your responses to negative emotions.

Learn more about DBT TIPP Skills 

For example, engage all five senses when you go for a walk outside. Pay attention to the trees or sky. Listen for wildlife. Touch the leaves or the earth. Smell flowers. Take a piece of fruit with you to taste along the way.

Pros and Cons

What are the pros and cons of acting on the urges you feel? Mindfully list them. Start a second list. This time, catalog the pros and cons of NOT acting on those urges. Keep this list with you (perhaps on your phone). Review it often — especially when a distressful experience feels as if it is looming.

Distraction

Intense negative feelings eventually burn out, but you may find it helpful to distract yourself until the emotions pass. DBT uses the acronym ACCEPTS to remind you how to keep your mind occupied when overwhelm sets in.

A: Activities requiring thought and concentration.

C: Contributing to something meaningful

C: Comparing your situation to something worse

E: Evoking a competing emotion

P: Pushing the emotions from your mind

T: Thoughts first, save emotions for later

S: Safe Sensations created to distract emotions

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.

The emotionally reactive aspects of being emotionally vulnerable can be extremely isolating. People may not understand your impulsivity or tendency toward angry outbursts. You may be frustrated by your difficulty connecting with people or feel perpetually misunderstood. All of this can make you very lonely.

DBT can help by encouraging you to learn and employ strategies for interpersonal effectiveness. These skills include clearly asking for what you need, saying no when necessary, and managing conflicts with other people.

Why are these important?

Mastering interpersonal effectiveness skills will help you become more aware and attuned to your effect on others. These skills are meant to help you see and hear yourself more clearly. You can take these steps to recognize how your behavior impacts your relationships then come up with solutions to make the kinds of positive changes that will facilitate better relationships.

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.

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.

Sometimes emotional pain can feel so intense that you have urges to hurt yourself. Suicidal thoughts and behaviors are specific problems addressed in DBT therapy.

If you have urges to kill yourself, we strongly recommend reaching out to a therapist for an appointment ASAP. If you cannot schedule an immediate appointment, you can call the National Suicide Prevention Lifeline 24/7 at 800-273-8255.

Here are some specific strategies you can try when emotional pain feels very intense.

These are examples of DBT behavioral skills you learn and practice in advance with your therapist so you are prepared to handle strong or intense emotions.

1. 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.

2. ***If you are very calm already and NOT emotionally intense, the best step to take is to go to sleep and wait.***

3. After bringing down your emotional arousal, don’t make any critical decisions.

4. 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.

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. 

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. 

Have you ever received caring messages from the hospital? Wouldn’t that make you feel seen and cared for?

“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. 

We offer groups for adults, parents 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 in your life and relationships. 

For teens and middle schoolers, the DBT group helps them with the same DBT skills, 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. 

For parents, the DBT skills group for parents teaches you how to effectively communicate with, connect with and support your teen. As a parent, there are specific skills can that greatly impact the reaction and response you receive from your teen. Go from feeling powerless to confident in our Parent DBT skills group.