DBT 101: It’s So Much More Than Just the Skills!
Dialectical behaviour therapy, or DBT is probably best known for its skills training: developing emotional mastery through its four skills areas of core mindfulness, relational effectiveness, emotion regulation and distress tolerance. These skills are famous for good reason: More often than not for those of us who live with overwhelming emotions, they really, really work!
But sometimes DBT gets overly reduced to its skills. Saying “DBT is about skills” is like saying “a rainforest is about rain.” In a rainforest the rain touches everything, and it nourishes and brightens the whole ecosystem. But a rainforest would lose its essential meaning without all the flora and fauna that live within it. It’s like that with DBT. While its skills touch every part of the process, nourishing and brightening the systems of a person’s life and emotions, DBT is also about gaining insight into the connectivity of those systems. Let’s take a closer look.
History
Dialectical behaviour therapy (DBT) was created by @DrMarshaLinehan in the early 1990’s. Other cognitive behaviour therapies (CBTs) in the 1970’s and 1980’s had helped to foster breakthrough experiences of recovery for people navigating a number of mental health issues (Beck, 2011), but these weren’t having such a helpful impact on the overwhelming emotions of people who were diagnosed with borderline personality disorder (BPD), who were self-harming and who were acting on suicidal urges. To cater to these people, Linehan created DBT.
Over the past few decades, DBT has spread to serving many other populations besides people with BPD, including people with goals related to addictions, eating, body image, depression, mania, anxiety and PTSD (Swenson, 2016). It has also been adapted and shown great evidence-based effectiveness for youth (Rathus and Miller, 2015).
DBT’s Common Elements with Other CBTs
Like other cognitive-behaviour therapies, DBT looks at the two-way flow between our thoughts and other behaviours, and how changing just one of these factors changes the rest. In neuroscience today, the term behaviour includes thoughts, emotions, body sensations, urges, motor functions, actions and expressions (Swenson, 2016).
Behaviourism is like gravity: a scientific force that exists, whether or not we do anything purposeful with it (Koerner, 2012; Van Dijk, 2012). Knowing how to navigate gravity means that we don’t usually put our dishes on the ceiling; knowing how to navigate behaviourism means that we don’t usually thank someone for closing the door in our face. So CBTs including DBT ask, How can we channel this force to help us, rather than to allow it to work against us? If we say to ourselves, “I can do this,” we are more likely to feel strong than if we say, “I’m such a loser.” If we say to someone else, “I love you,” they are more likely to have a warm feeling toward us than if we say “I hate you.” So CBTs including DBT help us to refine the behaviours that bring about these kinds of well-being.
Also like other CBTs, DBT promotes skills-development (Linehan, 2015) and homework as a way to generalize the benefits of the therapy to daily life — and to equip clients with mastery to eventually manage their own growth. CBTs including DBT consider therapy to be a form of training: It’s hard and exhausting work, like learning how to do chin-ups or how to speak a new language. But hard and focused work can really bring about a deepened sense of strength and capacity.
How DBT Differs from Earlier CBTs
The emphasis that earlier CBTs place on logic can be invalidating and alienating for those of us who experience overwhelming emotions. To meet these unique needs, DBT took on some major differences from previous CBTs. Here are just a few.
An Emotion-Focused Model
Rather than defaulting to logic, DBT’s home base is in emotions.
DBT values thoughts but considers them to be just one of the many factors (i.e., cognition, body sensations, neurochemistry, motor functions, urges, expressions and actions) that make up the “full system response” of an emotion (Linehan, 1993, p. 38). So rather than emphasizing rational thinking, DBT favours “intuitive knowing” (p. 214), or “listening to your gut,” which is the synthesis of logic and emotion into something greater than the sum of their parts. It’s this synthesis that sparks insight about what’s going on between our body and our mind, between our inner being and outer environment, and about what the links might be between some of these things. Insight about these links, especially about the missing links, allows us to both love and accept our present reality just as it is (losses, adversities, oppression and all) and to shape it into something that we experience as safer, and more just, fulfilling and sustainable.
Dialectics: Synthesizing Opposites
The “D” in DBT is for dialectics, which is the philosophy of holding two polarities or opposites at the same time until they synthesize into a greater whole. The central dialectic of DBT is acceptance-and-change (Linehan, 1993; 2015). It’s often necessary to embrace both wholeheartedly. So in DBT we bring kindness and acceptance to your reality just as it is (losses, adversities, oppressions and all). The paradox is that this accepting stance can be the thing that then helps you to shape and change your reality. A synthesis of acceptance-and-change would be to allow ourselves to change because we love ourselves just as we are, not to force change in ourselves to make ourselves lovable. Other dialectics are logic-and-emotion (the synthesis of which is wisdom or intuition), kindness-and-fairness, skepticism-and-optimism and vulnerability-and-strength.
One dialectic that has really anchored me in my life and that I think my clients appreciate about my presence is that of release-and-lament. When we experience compound loss and violence, it can seem like death and horror are all over. And they are. In one sense, we must release that which has been taken from us via death and violence. At the very same time and in another sense, we must lament, because doing so tells us that what has been taken matters to us and that we will not lose ourselves in passivity. It seems impossible to both release and lament death, violence, horror, but I think dialectics are all about reconciling the impossible in our minds and bodies.
The Radially Genuine Therapist: For Better and for Worse!
Unlike earlier CBTs, DBT considers the relationship between therapist and client to be a crucial microcosm of the other relationships in both people’s lives. Staying curious about the therapist-client relationship, in all of its comforts, strengths and disappointments, often uncovers missing links that can help the client (and therapist!) to get unstuck from relationship problems in their lives outside of therapy.
To foster this type of natural and realistic relationship, the DBT therapist embodies a radically genuine style that shifts between warmth and bluntness as might happen between old friends. The idea of a therapist being blunt at times might sound harsh compared to some other models of therapy, but people who navigate overwhelming emotions often feel reassured to know that their therapist won’t hide from them what they’re thinking. Many clients have had loved ones hide thoughts that if shared might have better protected those relationships from derailing. So DBT therapists commit to transparency with their clients, in order to both protect the therapeutic relationship and to protect and nurture the client’s relationships outside of therapy.
Validation
Since dialectics are about valuing multiple truths, DBT champions the validity of everything in some way or another. While earlier CBTs would ask whether a thought is rational or irrational, DBT looks for the “kernel of truth” in everything. DBT suggests that every emotion has a good reason to exist, even if it isn’t the most helpful reason at the present time. So where earlier CBTs might say, “You’re sad because of a distorted thought, so change the thought” DBT says, “Your sadness makes perfect sense based on X, Y, and Z.” DBT will advocate for us to change many unhelpful thoughts, but not without validating the underlying emotion that accompanies them. Validation helps us to learn to trust the inherent wisdom in our emotions, even the ones we hope to shift.
Mindfulness as the Heart of DBT
All of these aspects of DBT are rooted in the core principle and practice of mindfulness.
Mindfulness imbues every moment of DBT, The whole process is about noticing when our minds have “left” the task we’re focusing on (anything from breathing, to feeling, to working, to playing) and with gentle patience bringing our mind back to the task, over and over.
Sometimes in DBT we do focus on the breath, saying something like, “What’s it like to watch your breath as you feel that feeling?” Just as often, though, we might be focusing on our conversation with each other or on your recounting of an important experience you’ve had recently. As humans, we are predisposed to “leaving” repeatedly with our minds: leaving our bodies, leaving the place, leaving the moment, whether it’s because we’re scared, overwhelmed or just plain bored. In DBT, we stay really attentive to and curious about the times when we “leave.” The DBT therapist gently says, “Hey did you just leave? Where did you go? Would it be safe to come back, or not yet?” Over and over, we very gently and patiently bring our minds “back” to the point of focus: the breath, the body, the conversation or the memory. The discipline of noting what took us away and gently returning is what brings us the insight and wisdom of change.
One of my favourite mindfulness practices of DBT is fleshing out the story about an important experience from someone’s week. We consider all behaviours and events to be rich plot points of the experience. We consider each of these plot points to be linked to the next. We radically accept each link just as it is, so that insight can spark about how to shape the next story. In DBT, we call each of these stories a chain, and each of these plot points a link in the chain, because we value the links between each part. Sometimes the stories can get intense, so we “leave” for a while: we change the topic, we segue to a different story, we get stuck on thoughts about thoughts or emotions about emotions rather than the thoughts and emotions of our direct experience. Just like the breath in meditation, the chain in a DBT session brings us back to the story we’ve chosen to honour with our attention and curiosity. I really like Charlie Swenson’s (2016) comparison:
Rather than ‘back to the breath, back to the breath’ it is ‘back to the chain, back to the chain.’ The chain is something to ‘grab onto’….Even if the chain does not lead quickly to a remedy, it illuminates a path” (pp. 238-239).
DBT is a System, not a Curriculum
Hopefully by now it’s clear that DBT is so much more than its skills. Even the information shared here is just a slice of what this rich and complex model involves. Like a Zen riddle, DBT is a thought twist.
Emotions, dialectics, genuineness, validation, mindfulness.
If you want to develop excellent emotion-focused skills, then absolutely consider DBT. But also consider DBT if any of the following are true:
- you believe that your painful emotions are honourable and you want a therapy that both loves them and helps to alleviate them;
- you need a way to hold all the painful contradictions of life that “can’t be” and yet are nevertheless;
- you want a therapist whose genuineness can be as warm as it can be honest;
- you want change but also want to be valued for the wisdom in where you are right now;
- you’re terrified of “just being” but are also desperate to find a way to let go of the weight you’re carrying.
Most of all, consider DBT if the idea of befriending your overwhelming emotions seems just absurd enough to give you hope.
Alejandra can be reached via The Healing Collective and at http://lindanpsychotherapy.com
References
Beck, J.S. (2011). Cognitive Behavioral Therapy: Basics and Beyond, 2nd Edition. New
York: Guilford.
Koerner, K. (2012). Doing Dialectical Behavior Therapy: A Practical Guide. New York:
Guilford.
Linehan, M.M. (1993). Cognitive-Behavioral Treatment of Borderline Personality
Disorder. New York: Guilford.
Linehan, M.M. (2015). DBT Skills Training Handouts and Worksheets: Second Edition.
New York: Guilford.
Rathus, J.H., & Miller, A.L. (2015). DBT Skills Manual for Adolescents. New York:
Guilford.
Swenson, C. (2016). DBT Principles in Action: Acceptance, Change, and Dialectics.
New York: Guilford.
Van Dijk, S. (2012). DBT Made Simple: A Step-by-Step Guide to Dialectical Behavior
Therapy. Oakland: New Harbinger.