Dialectical Behaviour Therapy (DBT) is a psychotherapy developed by Marsha Linehan in the 1980s to treat borderline personality disorder. Many of the principles of DBT are rooted in mindfulness. DBT can also be used broadly in the treatment of depression, self-harm, suicidal ideation/attempts, and anxiety.
Although DBT is primarily used for treatment of borderline personality disorder, there is also evidence for its use in depression, substance use disorders, posttraumatic stress disorder, traumatic brain injuries, and binge-eating disorder.[1]
A detailed assessment is required before starting a course of DBT. Progress with therapy is tracked at weeks 1, 3, and 5. Patients are augmented with medications as needed. If the patient is not adhering to therapy, then they are recommended to consider stepping up to in-person group or individual therapy.
There are 4 stages of DBT (details of which will not be explained here). In brief, the first stage (Stage I) focuses on reducing of out-of-control behaviours that fall into 3 categories and are ranked in terms of importance as follows:
Once a patient has achieved reasonable control of severely dysfunctional actions, they can move to the next stage of treatment. Therapy in Stage II shifts its focus to increase a client’s ability to experience emotions without also experiencing trauma.[9] In Stage III, the goal is to synthesize the skills and insights gained to decrease symptoms that interfere with the achievement of personal goals. In the final stage, Stage IV, therapy focuses on resolving the client’s residual feelings of incompleteness, which may remain after the first 3 stages of therapy.
The four main components of DBT are:
Behavioural Chain Analysis (also known as functional analysis) is another technique used in DBT to help an individual understand the function of a particular behaviours. During a chain analysis of a problem behaviour (e.g. - cutting and self-harm), the individual tries to uncover all the factors that led up to that behaviour. In the analysis, the therapist works with the patient to identify vulnerabilities, triggers for the behaviours, and links in the chain that lead to the final behaviour.
Validation is a core component of DBT. Marsha Linehan developed the Six Levels of Validation for use in DBT (see this great article for more information):
Learning and practising interpersonal effectiveness skills are a core component of DBT. Thinking about a patient's presentation in the context of the Stress-Vulnerability Model can help patients choose to use which skills at what time. There are four key skills that should be learned in therapy:
The principles of Wise Mind, Emotion Mind, and Reasonable Mind can also be applied towards addictions.
“What” Skills are what you do when you practice mindfulness: observe, describe, or participate. Do only one of these activities at a time.
“How” Skills are how you practice when you practice mindfulness: nonjudgmentally, one-mindfully, and effectively. Although the “what” skills should only be done one at a time, the “how” skills can be done together.
Check the Facts is a core strategy in also used in other cognitive therapy interventions like cognitive behavioural therapy. Humans often react to our thoughts and interpretations of an event rather than to the facts of the event. Checking the facts means checking if our emotional reactions actually fit the facts of the situation. It also means looking out for interpretations, judgments, and opinions. Avoid “good vs. bad”, “should vs. shouldn't” and other judgmental language. Instead try to use language like “this is helpful or not helpful.” Changing our beliefs, assumptions, and interpretations of events to fit the facts can change our emotional reactions.
Use opposite action when your emotion or its intensity does not fit the facts.
Emotion | |
---|---|
Love | • AVOID the person, animal or object you love • DISTRACT from thoughts of the person animal or object • REMIND yourself of the “cons” of loving • Do the OPPOSITE of other loving action urges |
Sadness | • Get ACTIVE; approach, do not avoid. • Do things that make you FEEL COMPETENT and self-confident. |
Shame | When your behaviour does not violate your own moral values: • Make your personal issues PUBLIC with people who won’t reject you • Engage in behavior that sets off shame OVER AND OVER in public • Do the OPPOSITE of other shame action urges When your behaviour does violate your own moral values: • APOLOGIZE publically • REPAIR the transgression • MAKE THINGS BETTER; or work to prevent or repair similar harm for others • COMMIT to avoiding that mistake in the future • ACCEPT the consequences gracefully |
Guilt | When you will not be rejected if found out: • Make your personal characteristics PUBLIC with people who won't reject you • Engage in behaviour that sets off guilt OVER AND OVER AND OVER in public When you will be rejected if found out: • HIDE or USE SKILLFUL MEANS if you want to stay in the group • Join a NEW GROUP that fits your values • Do what makes you feel guilty OVER AND OVER with your new group |
Emotion | Opposite Action |
---|---|
Fear | • Do what you are afraid of doing over and over again • APPROACH events, places, tasks, activities, people you are afraid of • Do things to give yourself a sense of CONTROL and MASTERY over your fears |
Anger | • Gently AVOID person you are angry with (rather than attacking) • Take a TIME-OUT and breath in and out deeply and slowly • Do something a little bit NICE (rather than mean or insulting • Do the OPPOSITE of other angry action urges |
Disgust | • MOVE CLOSE. Eat, drink , stand near, or embrace what you found disgusting • Be KIND to those you feel contempt for; step into the other person's shoes |
Envy | • Inhibit destroying what the other person has • Do the OPPOSITE of envious action urges • COUNT YOUR BLESSINGS • Make a list of the things you are thankful for |
Jealousy | • LET GO of controlling others' actions • SHARE what and who you have in your life |
Emotional distress and anguish can be reduced by decreasing risk factors that can make one more vulnerable to negative emotions and moods. The acronym ABC PLEASE
can help with this.
A
- Accumulate positive emotionsB
- Build masteryC
- Cope ahead of time with emotional situationsP
- (Treat) Physical illness L
- (Treat) PhysicaL illness E
- (Balance) EatingA
- Avoid Mood-Altering SubstancesS
- (Balance) SleepE
- Exercise
Interpersonal conflicts can arise when there is ineffective communication. DEAR MAN
is a skill to ask for something effectively, say no to another’s request, or to resist pressure and maintain your point of view. GIVE
is a skill aimed at maintaining or improving your relationship with the other person while you try to get what you want in the interaction. FAST
is a skill to keep or improve your self-respect and self-esteem while you try to get what you want in an interaction. Think about what you want out of an interaction and pick a skill to use.
D
- Describe the situation (Describe just the facts, and only the facts)E
- Express your feelings (Express how you feel)A
- Assert yourself (One can be passive, aggressive, passive aggressive, or assertive. Choose to be assertive over the other methods of communication)R
- Reinforce (By expressing thanks to the individual, or is there a benefit or 'something in it' for the other person?)M
- Mindful (Focus on the task at hand, and don't let emotions or judgments come in the way)A
- Appear confident (Notice the key word is 'appear')N
- Negotiate (If you don't get what you want, it's important to negotiate)You | Others | |
---|---|---|
Aggressive | + | - |
Passive | - | + |
Passive-Aggressive | - | - |
Assertive | + | + |
G
- Gentle (Have a relaxed body language, if you body is relaxed, then your emotions are also relaxed)I
- Interest (Show genuine curiosity, if is hard to be angry if you're curious. You can also show interest by nodding, having eye contact, and asking questions)V
- Validate (Validation means showing the person that at least some part of their experience is legitimate, but only validate what makes sense to you) E
- Easy MannerF
- (Be) Fair (Be fair to both your needs and the other person's needs)A
- (No) Apologies (Don't say sorry unless you've hurt someone)S
- Stick to Values OnlyT
- (Be) TruthfulWhen choosing goals, it is important to choose goals that follow the SMART acronym to ensure they can be feasibly done. A goal should feel 80% do-able and 20% challenging so as to strike the right balance.
S
- SpecificM
- MeasurableA
- AchievableR
- RealisticT
- Time-Limited