The basics of dialectical behavior therapy

[Storyteller.]

The basics of dialectical behavior therapy
By Anonymous

Dialectical behavior therapy, or DBT, is a branch of cognitive behavioral therapy that deals with the theory of dialectics – two seemingly opposite notions that exist simultaneously. The basis of DBT is to encourage participants to accept themselves as is while still aiming for the possibility of change. The idea of integrating acceptance and change was paradoxical, and of course, dialectical, when it was first proposed in the 1980s by Marsha M. Linehan. However, it turned out to be beneficial for many participants, who often found purely cognitive behavioral therapy (CBT)-based treatments to be invalidating. By integrating these two opposing odds, Linehan created a new form of therapy aimed primarily at severely suicidal individuals and those affected by borderline personality disorder (BPD). DBT has since extended its capabilities, reaching out to a much broader spectrum of people with various mental disorders.

One of the reasons why DBT works so well for participants is that it helps to reinforce the individual’s strengths, promoting a more solid foundation for self-esteem to grow. It also helps to identify unhelpful thoughts and belief systems that impair a person’s ability to lead a meaningful existence in today’s world. These thoughts and beliefs may include feelings of failure, unhelpful perfectionism, or a belief that one is worthless. By working closely with a therapist, participants will develop a customized path to recovery suiting their specific needs, cultivating skillful behavior that is beneficial in the long-term.

DBT has clear therapeutic goals. These are addressed in order of their impact on the participant's life. The first thing to be addressed, which has the greatest impact on the participant, is to decrease life-threatening behaviors. In the context of DBT, self-harm is considered a life-threatening behavior. Other goals will not be addressed until these behaviors are managed. DBT also addresses therapy-interfering behaviors, such as not doing therapy-based exercises or skipping sessions. The final, and most important thing addressed through the DBT program, is to increase the participant's quality of life.

DBT operates through four modules: Mindfulness, Distress Tolerance, Interpersonal Effectiveness, and Emotion Regulation. These four modules provide crucial skills for addressing problematic behaviors and learning more helpful ways to react to various situations. These skills range from staying in the moment (being physically and mentally 'present'), regulating emotion, coping with distress, and gaining effectiveness in relationships. All of these modules influence each other and work as a whole to find balance in the participant’s life.

Mindfulness

Mindfulness is considered the foundation of DBT. Derived from Eastern Zen philosophy, it promotes the awareness of internal experiences, encouraging the participant to identify thoughts, feelings, and urges that may lead to unhelpful behaviors or thought patterns. Mindfulness teaches how to pay attention in a particular way: on purpose, in the present moment, and non-judgmentally. It turns one's attention to the different states of mind, those being Emotional Mind, Rational Mind, and Wise Mind. While Emotional and Rational Mind deal with the more emotionally charged and logical aspects of awareness, Wise Mind lies somewhere in the middle – a combination of the two previous states. Its job is to balance logic and emotional reasoning in the art of decision making. One of the core mindfulness skills is learning to recognize what manner of thinking is occurring at a given time. Wise Mind is seen as the “ideal” state of mind and ensures that decisions are neither too factually nor too emotionally based. One of the goals of Mindfulness is to help participants to be able to access Wise Mind more frequently.

Participants can get in touch with these states of mind by utilizing “What” and “How” skills. “What” skills answer the question, “What do I need to do?” They include Observe (taking in what is happening around you), Describe (putting words to that experience), and Participate (immersing yourself fully in the moment). But “how” exactly does one do that? “How” skills include Non-Judgmentally (simply absorbing the scene before you without ascribing positive or negative characteristics to it), One-Mindfully (doing one thing at a time), and Effectively (doing what needs to be done to promote success in the moment, without dwelling on how things “should” be). These skills come together to form core Mindfulness, and a solid basis on which the other components of DBT can operate.

Distress Tolerance

We all experience distress from our environments or internal experiences from time to time. However, for some individuals, emotional upset can seem intolerable and overwhelming. These feelings of distress can lead to an engagement in negative behaviors, such as self-harm or substance abuse, in an attempt to escape discomfort. While many therapeutic practices focus on how to avoid pain, the Distress Tolerance module of DBT maintains that emotional pain is unavoidable at times, but that participants can learn to cope effectively with the ups and downs of life through acceptance and tolerance.

Many people are familiar with the Serenity Prayer, which is often used in twelve-step programs: “Grant me the serenity to accept the things I cannot change, courage to change the things I can, and the wisdom to know the difference.” In many ways, this reflects a similar teaching of DBT: radical acceptance. Radical acceptance is first taught in Distress Tolerance and involves accepting realities that one cannot change. As discussed in Mindfulness, participants are encouraged to approach a situation non-judgmentally and experience it fully without attempting to fight or distort reality. In doing so, they become less susceptible to experiencing prolonged negative emotions by relinquishing their control over the situation.

However, radical acceptance cannot work alone. Within the Distress Tolerance module, there are also four skill categories. These include:
Distraction (diverting your attention from your distress to other worthwhile activities, such as hobbies or exercise), Self-Soothing (engaging the senses - sight, touch, hearing, smell, and taste - in indulgent or comforting sensations to soothe yourself, such as looking at a pretty picture or eating a piece of chocolate), Improving the Moment (using mental imagery to improve your current situation, such as imagining yourself somewhere that feels safe and comforting to you), and Pros and Cons (weighing the positives and negatives of tolerating the distress and not tolerating the distress - for example, coping through self-destructive behaviors).

To make retrieving this information in a moment of crisis easier, DBT offers two acronyms: ACCEPTS and IMPROVE. ACCEPTS goes along with the Distraction skills category and encourages the participant to:

• Find Activities to distract oneself, such as hobbies or exercise.
• Contribute to society through volunteer work or a kind gesture done for someone.
• Compare oneself to others who are less fortunate and find reasons to be grateful.
• Identify negative Emotions and act the opposite way, such as going out when one feels like isolating.
• Push thoughts away by focusing on something unrelated, such as listening to music and focusing one's attention on the lyrics.
• Replace negative Thoughts by doing an activity like counting to ten.
• Distract oneself with physical Sensations, such as holding an ice cube

IMPROVE goes along with the Improve the Moment skills category and encourages participants to:

• Use Imagery to envision a safe place or negative emotions draining away.
• Find a Meaning for the pain one is experiencing.
• Pray to a higher power (whether a god or the wisdom of oneself) for strength in the moment.
• Relax by breathing deeply or listening to soothing music.
• Remain One-mindful, or do only one thing at a time.
• Go on a mini Vacation, or imagine doing something pleasant and unrelated to the situation at hand.
• Encourage oneself through positive self-talk.

By choosing one of these skills to focus their attention on, participants learn effective and productive ways of coping with their distress, including channeling their destructive desires into artistic works or giving back to and being part of a community.

Interpersonal Effectiveness

The way we interact with others has a significant effect on our emotional well-being. Similarly, our emotional well-being has a significant effect on the way we interact with others. For someone suffering from a disabling mental disorder, interactions may be rocky and riddled with guilt, manipulation, or frequent emotional outbursts. On the other hand, one may have trouble saying "no" when appropriate and allow others to dominate their life. The Interpersonal Effectiveness module of DBT addresses these issues, aiming to restore a healthy balance to participants’ relationships and increase interpersonal satisfaction for both the participant and the loved ones.

Marsha Linehan outlines three factors that must be thoughtfully considered in interpersonal exchanges. The first is one’s objectives, or what one hopes to gain from the interaction. The next is how important the relationship is to the person and how they want the other person to feel about them. Lastly, there is the ever-important matter of self-respect – how the person wants to feel about themselves once the interaction is over. These factors should be prioritized prior to the interaction, in order of importance to the individual. For some people, self-respect may take priority over all else, with the relationship being the next most important, and the objectives being the least important. Some people may be more concerned with maintaining the relationship or gaining their objectives. Prioritizing allows for the possibility of a more satisfying interaction, for in the event that all factors cannot be fulfilled, the person will likely be happier if their top priority is met.

Once these factors have been prioritized, participants turn to three acronyms: DEARMAN, GIVE, and FAST. DEARMAN deals with the objectives – getting what one wants out of an interaction. GIVE aids in maintaining the relationship, and FAST protects one’s self-respect. Often, these acronyms work in conjunction for a well-rounded and healthy interaction, but depending upon their objectives, participants may choose one to focus their attention on.

DEARMAN asks participants to:

• Describe the situation to the other person in specific and non-judgmental terms. For example, “I know lately that we've been talking about getting a cat, but Dad doesn’t want one.”
• Express their feelings about the situation: “It makes me feel really sad that Dad doesn’t want a cat.”
• Assert their wishes in a clear and authoritative but level-headed manner: “I’d really like to get a cat.”
• Reinforce what they want, or state why the outcome would be beneficial: “I think it would be a good way to teach me responsibility.”
• Stay Mindful and keep one’s attention focused on the discussion at hand, without becoming distracted by overactive thoughts or emotions.
• Appear confident, maintaining good posture and eye contact, which will increase the credibility of the case.
• Negotiate when appropriate. Sometimes, it’s not enough to simply state our terms; sometimes, we must compromise in order to get what we want out of an interaction and to partially satisfy both individuals. For example, “If we get a cat, I promise to change the litter box.”

GIVE encourages participants to:

• Take up a kind and Gentle approach to the conversation, being careful not to personally attack or otherwise begrudge the other person.
• Listen intently to what the other person has to say.
• Appear Interested by not interrupting and allowing them to finish speaking.
• Validate the other person’s feelings by accepting and acknowledging their personal concerns and desires.
• Maintain an Easy manner, illustrated by smiling and having a good sense of humor.

FAST requests that participants:

• Be Fair to both themselves and the other person in the interaction, without taking advantage.
• Not Apologize excessively -- only when it is warranted. This means no apologizing for having a need or asserting that need.
• Stick to one’s core values and not compromise oneself for the sake of a particular outcome by doing something one will regret later.
• Be Truthful and do not exaggerate the case or behave helplessly in order to pull on the person’s heart strings or otherwise manipulate them.

All of these skills come together to form healthy and balanced relationships. With practice and perseverance, participants can learn to dull the emotional whirlwind and restore equilibrium to their home lives, friendships, and romantic pursuits.

Emotion Regulation

Imagine you are at a beach, observing the gentle ebb and flow of the waves. While this scene is bound to stir up emotions of its own, could you liken it to an actual emotional experience? The teachings of DBT say that you can. In fact, that is the basis of Emotion Regulation: to learn to experience one’s emotions as coming and going like a wave. Sometimes the waves are violent, thrashing about and threatening to capsize any ship in their path. Other times, they are calm and sensuous, like one would experience on the perfect beach day. Whatever the situation, none are lasting, and they must always return to a baseline. In this way, participants can learn to reduce their emotional suffering and increase positive experiences by courageously riding out the wave that is life.

Understanding and being able to label one’s emotions is key in order to reduce suffering. Too often participants use unspecific and vague terminology in reference to their experience, such as “good,” “bad,” or “okay,” that do not really speak to any particular emotional state. It is more appropriate for participants to use “emotion words,” such as “happy,” “sad,” or “angry,” when describing life from their point of view. DBT teaches that unlabeled or vaguely labeled emotions are more difficult to manage, for how can one effectively treat something if they do not know what it is? That would be similar to a doctor attempting to treat someone before a diagnosis has been reached.

It is said that there are six primary emotions: happiness, sadness, anger, surprise, disgust, and fear. Primary emotions are a person’s first reaction to an event and are innately triggered, meaning that they require no thinking. They are instinctual. For example, one hears about a death and they become sad. Unfortunately, primary emotions are often not lasting, as they tend to be usurped by secondary emotions. This may make it difficult to pinpoint what is actually bothering the person. Secondary emotions are a person’s second reaction to an event, and may either be triggered directly by the primary emotion (for example, fear turning to anger to prepare one for a fight) or by a more complex and conscious analysis of the situation.

Luckily, emotional vulnerability (that is, being vulnerable or prone to negative emotions) can be reduced through use of the acronym PLEASE Master. PLEASE Master instructs that one should treat all Physical ILlness, balance their Eating, Avoid any drugs (including alcohol) that may have mood-alerting effects, get enough Sleep, and Exercise regularly. Finally, a person can take control of their life by practicing Mastery, which includes taking on tasks that reinforce feelings of accomplishment. This may involve getting the dishes done, finishing one’s homework, or returning phone calls. No task is too small or too ordinary!

However, one must also acknowledge that negative emotions are a normal part of life. While one can engage in preventative strategies to help ward them off, the fact of life is that sometimes they will occur. Thankfully, emotional suffering can be reduced. But doesn’t suffering go hand-in-hand with negative emotions? A lot of people might be surprised to find out that no, that is not necessarily the case. Suffering occurs when a person ascribes negative meaning and judgments to their experience. In many ways, dwelling on how things “should” be, rather than accepting them as they are (as discussed in Mindfulness), is a cause of deep emotional suffering. One can experience the emotion of sadness without the deep-seated distress that so often comes with it.

But how exactly does one decrease emotional suffering? Three key skills help to accomplish this: pursuing and paying attention to positive experiences, letting go of painful emotions, and practicing Opposite Action.

Acting opposite to emotion is achieved by acting in a way not associated with the emotion being felt. (For example, things like doing something active when feeling depressed, doing something calmer when angry/agitated, doing something happy/soothing when sad.) By providing environmental feedback to the brain, behaviors that are not fueled by the emotion being felt can trigger a change from a negative or distressing emotion to a more manageable emotion. Failing that, acting opposite can decrease the intensity of the emotion being felt. The purpose of acting opposite is to de-escalate the emotion, which decreases the suffering, simultaneously decreasing the vulnerability to the emotion.

Building positive experiences is achieved in three main ways. This can be done in both the short-term and the long-term. The short-term way of building positive experiences is to do pleasant things that are possible now. Participants of DBT are often given a pleasant events schedule and are encouraged to do one thing a day from this schedule. Long-term, participants are asked to look at building a life worth living, which looks different for everybody and is generally investigated more in individual therapy. In general, long-term ways to increase positive experiences involve accumulating positives – making lists of what's wanted, setting goals, attending to relationships, and avoiding avoidance.

Part of building positive experiences is to be mindful of positive experiences as they are occurring. When things are going well, or feeling good, it is important to acknowledge this. Even if the event is small, use the Mindfulness skills to refocus and remain aware that something positive is happening. It also helps to be unmindful of worries – distracting from thoughts such as when the positive experience will end.

DBT is a therapy that benefits many. As stated previously, it is particularly helpful for those with borderline personality disorder and suicidal thoughts. However, it also lends a helping hand to those grappling with impulsive behaviors such as self-harm, substance abuse, over-spending, and disordered eating. People who have difficulties with interpersonal relationships, social isolation, anger, or feelings of sadness or emptiness may benefit as well. The progress seen in DBT will vary from person-to-person, based on one’s commitment to therapy and the severity of the issues being addressed. However, with time and patience, DBT skills can be mastered and put to good use on a regular basis, allowing participants to restore balance to their everyday lives.