Dialectical Behavioral Therapy for Emotional Regulation

Introduction

Dialectical behavior therapy (DBT) evolved from Marsha Linehan s efforts to create a treatment for multiproblematic, suicidal women. Linehan combed through the literature on efficacious psychosocial treatments for other disorders, such as anxiety disorders, depression, and other emotion-related difficulties, and assembled a package of evidence-based, cognitive-behavioral interventions that directly targeted suicidal behavior. Initially, these interventions were so focused on changing cognitions and behaviors that many patients felt criticized, misunderstood, and invalidated, and consequently dropped out of treatment altogether.

Dialectical behaviour therapy (DBT) is a type of talking therapy. It s based on cognitive behavioural therapy (CBT), but it s specially adapted for people who feel emotions very intensely. 

The aim of Dialectical behaviour therapy is to help you: 

• understand and accept your difficult feelings  
• learn skills to manage them  
• become able to make positive changes in your life. 

‘Dialectical’ means trying to understand how two things that seem opposite could both be true. For example, accepting yourself and changing your behaviour might feel contradictory. But dialectical behavior therapy teaches that it s possible for you to achieve both these goals together.

How does dialectical behavior therapy (DBT) work?

The standard DBT treatment package consists of weekly individual therapy sessions (approximately 1 hour), a weekly group skills training session (approximately 1.5–2.5 hours), and a therapist consultation team meeting (approximately 1–2 hours). 

Five functions of DBT.

Dialectical behaviour therapy is a comprehensive program of treatment consisting of individual therapy, group therapy, and a therapist consultation team. In this way, (DBT) is a program of treatment, rather than a single treatment method conducted by a practitioner in isolation. Often, clinicians are interested in applying dialectical behaviour therapy but find the prospect of implementing such a comprehensive treatment to be daunting. In this case, it is important to remember that the most critical element of any dialectical behavior therapy program has to do with whether it addresses five key functions of treatment. Although the standard package of DBT has the most empirical support, different settings and circumstances may necessitate innovative and creative applications of DBT. In all cases, however, it is critical that any adaptation of dialectical behavior therapy (DBT) fulfils the following five functions:

Function #1: Enhancing capabilities.

Within dialectical behavior therapy, the assumption is that patients with BPD either lack or need to improve several important life skills, including those that involve:
(a) regulating emotions (emotion regulation skills),
(b) paying attention to the experience of the present moment and regulating attention (mindfulness skills),
(c) effectively navigating interpersonal situations (interpersonal effectiveness), and
(d) tolerating distress and surviving crises without making situations worse (distress tolerance skills).

As such, improving skills constitutes one of the key functions of DBT. This function usually is accomplished through a weekly skills group session, consisting of approximately 4 to 10 individuals and involving didactics, active practice, discussion of new skills, as well as homework assignments to help patients practice skills between sessions.

Function #2: Generalizing capabilities.

If the skills learned in therapy sessions do not transfer to patients daily lives, then it would be difficult to say that therapy was successful. As a result, a second critical function of DBT involves generalizing treatment gains to the patient s natural environment. This function is accomplished in skills training by providing homework assignments to practice skills and troubleshooting regarding how to improve upon skills practice. In individual therapy sessions, therapists help patients apply new skills in their daily lives and often have patients practice or apply skillful behaviors in session. In addition, the therapist is available by phone between sessions to help the patient apply skills when they are most needed (e.g., in a crisis).

Function #3: Improving motivation and reducing dysfunctional behaviors.

A third function of dialectical behaviour therapy involves improving patients motivation to change and reducing behaviors inconsistent with a life worth living. This function primarily is accomplished in individual therapy. Each week, the therapist has the patient complete a self-monitoring form (called a “diary card”) on which he or she tracks various treatment targets (e.g., self-harm, suicide attempts, emotional misery). The therapist uses this diary card to prioritize session time, giving behaviors that threaten the patient s life (e.g., suicidal or self-injurious behaviors) highest priority, followed by behaviors that interfere with therapy (e.g., absence, lateness, noncollaborative behavior), and behaviors that interfere with the patient s quality of life (e.g., severe problems in living, unemployment, or severe problems related to Axis I disorders).

After prioritizing the behavioral targets for a given session, the therapist helps the patient figure out what led up to the behavior(s) in question and the consequences that may be reinforcing or maintaining the behavior(s). The therapist also helps the patient find ways to apply skillful, effective behavior, solve problems in life, or regulate emotions. In terms of enhancing motivation, the therapist actively works to get the patient to commit to behavior change, using a variety of “commitment” strategies.

Function #4: Enhancing and maintaining therapist capabilities and motivation.

Another important function of dialectical behavior therapy involves maintaining the motivation and skills of the therapists who treat patients with BPD. Although helping multiproblematic BPD patients can be stimulating and rewarding, these patients also engage in a potent mix of behaviors that can tax the coping resources, competencies, and resolve of their treatment providers (i.e., suicide attempts, repeated suicidal crises, behaviors that interfere with therapy). As a result, one essential ingredient of an effective treatment for BPD patients is a system of providing support, validation, continued training and skill-building, feedback, and encouragement to therapists.

To address this function, standard DBT includes a therapist consultation-team meeting, for which dialectical behavior therapy (DBT) therapists meet once per week for approximately 1 to 2 hours. The team helps therapists problem-solve ways to implement effective treatment in the face of specific clinical challenges (e.g., a suicidal patient, a patient who misses sessions). In addition, the team encourages therapists to maintain a compassionate, nonjudgmental orientation toward their patients; monitors and helps reduce therapist burnout; provides support and encouragement; and sometimes employs structured training/didactics on specific therapeutic skills.

Function #5: Structuring the environment.

A fourth important function of DBT involves structuring the environment in a manner that reinforces effective behavior/progress and does not reinforce maladaptive or problematic behavior. Often, this involves structuring the treatment in a manner that most effectively promotes progress. Typically, in dialectical behavior therapy (DBT), the individual therapist is the primary therapist and is “in charge” of the treatment team. He or she makes sure that all of the elements of effective treatment are in place, and that all of these functions are met.

Structuring the environment may also involve helping patients find ways to modify their environments. For instance, drug-using patients may need to learn how to modify or avoid social circles that promote drug use; patients who self-harm sometimes need to learn how to make sure that their partners or significant others do not reinforce self-harm (i.e., by being overly soothing, warm, or supportive). In DBT, the therapist normally has the patient modify his or her environment, but at times, may take an active role in changing patients environments for them (e.g., if the environment is overwhelming or too powerful for the patient to have a reasonable degree of influence).

What is the Difference Between Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT)?

A key difference between CBT and DBT lies in the concept of validation and relationships. DBT teaches that our experiences are real/valid and to accept them as such. It also informs us that we must make positive changes if we wish to have a healthy relationship with the ever-changing, and often-challenging world around us. This can be tough given these are two opposing constructs however, they are vital in the DBT process. Although both CBT and DBT incorporate cognitive-behavioural techniques, DBT is a modified version that places more emphasis on the emotional and social aspects of a person’s life. Originally developed to help individuals cope with extreme emotions that would often result in harmful behaviours, dialectical behavior therapy works towards reducing one’s emotional distress that negatively impacts their wellbeing and the way they interact with their surroundings. 

More specifically, Dialectical Behavioral (DBT) Therapy focuses on skills training and includes mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance. These four components are the key to successfully implementing this modality in one’s day to day life. Because they are such important therapeutic skills, let’s break them down a little further:

Mindfulness

As with mindfulness-based therapy itself, this skill helps one to live in the present moment and accept what is happening in the here-and-now. With anxiety, we have a tendency to live in the future and try to predict what will happen in every possible scenario. The problem with this is no one can predict the future and therefore it will always remain unknown to some degree. Conversely, with depression, we have a tendency to become stuck in the past and reflect on what could have been or should have been. The problem here lies in the inability to change the past or travel in time. With mindfulness, we can eliminate these two attempts that are ultimately beyond our ability and accept that what is happening in the present moment is all that we have control over. This can be quite challenging at first, but with practice, it can be liberating and a means of letting go of the extra weight that we perceive life to pile on. This skill may incorporate practices like mindful meditation, body scans, or simply taking a moment to focus on our breath. We feel the stress of the day leave with each breath that exits our body, and we breathe in the experiences that the present moment has to offer. By letting go of the need to control, we let go of the distressing emotions and the rigid expectations we hold of ourselves and others.

Emotion Regulation

This is the ability to regulate our emotions so that they do not get to the point of controlling/impacting our thoughts and behaviours. By learning strategies to manage and change the intense emotions that are causing problems in our lives, we can, in turn, live more peacefully with the world and the people around us. This skill often encapsulates three goals: to understand the emotion, to reduce emotional vulnerability, and to decrease emotional suffering. We can better regulate something, in this case, an emotion, when we understand what it is we are trying to regulate. This leads us to “labelling” (i.e. angry, sad, scared, confused, etc.) From there, we can say to ourselves “Ok, I know what I am feeling, now why am I feeling that way?” This then leads us to tease apart primary and secondary emotions. The primary emotion is the initial reaction, whereas the secondary emotion is a reaction to the subsequent thought (i.e. I got really

1.angry with the cashier at the grocery store and now I am feeling 2.depressed because I am a terrible person for feeling this way).

When we process our anger as a normal emotion, we can reduce the vulnerability associated with the secondary emotion (i.e. depressed) and decrease our overall suffering. It takes time, practice and guidance but is an incredible skill to reference when the world seems a bit unfair or chaotic.

Interpersonal Effectiveness

This is the ability to ask another person for what they need and to say no to them when necessary, all the while still maintaining self-respect and healthy relationships with others. In other words, this is assertive communication and boundary setting. Being able to ask other people what they need and to assert oneself in a conversation is so important because we are not mind-readers and therefore if we do not ask someone what they need (either from us, from the interaction or from their situation) we are left guessing and assuming. And we all know what happens when we assume… Doing this can also lead to increased tension, frustration and overall hopelessness. From there, we must also keep in mind our boundaries and be able to recognize if what they need is beyond our realistic abilities. If it is not, then we offer our assistance and do what we can to help. If it is, then we learn the art of saying No. By understanding our boundaries and sticking to them, it prevents us from taking on an unrealistic task, from feeling burnout, and/or from feeling guilty or useless that we could not provide what they needed. If we do not know our boundaries, and if we do not say no, then we are setting ourselves up to feel negative because it was out of our scope, to begin with. It is asserting ourselves in the conversation while maintaining our boundaries to foster healthy relationships with ourselves and others.

Distress Tolerance

This is the ability to cope during a crisis, particularly when it is impossible to change, and accepting the situation as it is, rather than how it should be. Let’s discuss that word for a moment, “should”. The number of times we use this word in a day can be astonishing. But, what it does is make us feel as though we have the power to change the past, other people, the world, the future, and everything in between! It makes us feel guilty for not doing something and allows us to dwell on a hypothetical situation that has not, nor potentially will, ever happen. As one can imagine, this is distressing and because we do not like feeling distressed, our natural inclination is to avoid it. This works when we move our hand away from a hot object or when we eat something because our stomach is growling, but when it comes to our emotions, it actually makes matters worse. Fear and avoidance are like a magnifying glass for distress and can amplify it to the point that it feels more distressing later on. Instead, we learn that negative emotions, although uncomfortable, are normal and will pass. Emotions happen in moments and moments can change! Distress tolerance helps us broaden our capacity to withstand negative emotions or physical discomfort. Have you ever wondered how some people can ‘keep their cool’ so easily? Well, it could be that they are very good actors OR, that they have learned the skill of distress tolerance. The saying “it is what it is” can sum this skill up nicely and reminds us that we are not avoiding or washing away the distress, we are simply preventing ourselves from doing something that will make it worse in the future.

When is Dialectical Behavior Therapy used?

Initially developed to treat individuals diagnosed with Borderline Personality Disorder, dialectical behaviour therapy has expanded its repertoire to successfully treat individuals suffering from depression, bipolar disorder, posttraumatic stress disorder, substance abuse and a variety of eating disorders, including bulimia and binge-eating. It is typically used during one-on-one therapy with a trained professional who can ensure that each of the four pillars we talked about earlier are being addressed. The therapist will also help the individual remain motivated and properly apply the learned skills in their day to day life. Regular sessions on a weekly basis are most effective with this type of therapy. The therapeutic relationship is also very important and the therapist holds an active role with the client both between and during sessions. Dialectical Behavioral (DBT) Therapy also consists of skills groups wherein participants can have the opportunity to practice their skills with one another in a group setting. This environment provides mutual support, an opportunity to share lived experiences and is a great way to directly practice creating and maintaining healthy relationships.

Benefits of Dialectical Behavior Therapy

In Dialectical Behavior Therapy (DBT), the collaborative effort between the patient and therapist aims to reconcile the apparent conflict between self-acceptance and the need for change, fostering positive transformations in the individual undergoing treatment. A crucial aspect of this process involves validation, wherein the therapist acknowledges that an individual s actions "make sense" within the context of their personal experiences, without necessarily endorsing these actions as the optimal solution to a problem.

DBT is implemented across various therapeutic settings, encompassing group skills training, individual psychotherapy, and phone coaching. The six key components of Dialectical Behavioral (DBT) Therapy are:

• Acceptance and Change: Individuals learn strategies to accept and tolerate their life circumstances, emotions, and self. Simultaneously, they develop skills to facilitate positive changes in behaviors and interpersonal interactions.
• Behavioral: Participants analyze problematic or destructive behavior patterns and acquire tools to replace them with healthier and more effective alternatives.
• Cognitive: Focus is placed on modifying thoughts and beliefs that prove ineffective or unhelpful.
• Collaboration: Effective communication and teamwork are emphasized, involving collaboration among the therapist, group therapist, and psychiatrist.
• Skill Sets: Individuals acquire new skills to enhance their capabilities in managing emotions, interpersonal relationships, and life challenges.
• Support: Recognition and utilization of positive strengths and attributes are encouraged, fostering a supportive environment for personal growth.

In essence, Dialectical Behavioral (DBT) Therapy provides a comprehensive framework that combines acceptance and change, behavioral and cognitive strategies, collaborative efforts, skill development, and ongoing support to promote holistic well-being and positive transformations in individuals.

How to Get Started With Dialectical Behavior Therapy?

To determine if DBT is a suitable approach for your needs, consulting with a qualified professional trained in this method is crucial. They will assess your symptoms, treatment history, and therapy objectives to ascertain the appropriateness of Dialectical Behavioral (DBT) Therapy for you. If you believe you or someone you care about could benefit from DBT, it s essential to engage in a conversation with a healthcare provider or mental health professional experienced in this therapeutic approach. However, locating DBT therapists can sometimes be challenging. You can inquire with your current healthcare provider, therapist, or another trusted mental health professional for a referral to a colleague specializing in dialectical behavior therapy (DBT). Additionally, online therapists who offer DBT may also be a viable option.

Things to Consider About Dialectical Behavior Therapy

Engaging in Dialectical Behavior Therapy (DBT) demands a substantial time investment. Beyond attending scheduled therapy sessions, individuals are tasked with completing assigned "homework" to practice skills outside of their individual, group, and phone counseling sessions. This aspect of the treatment may present a hurdle for those who struggle to consistently fulfill these assignments.

Furthermore, the application of certain skills during therapy may prove challenging for some individuals. Throughout various phases of the treatment, individuals delve into traumatic experiences and emotional distress, potentially encountering upsetting emotions.

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