Dialectical Behavioral Therapy (DBT): Learning How To Think Better

Psychotherapy (commonly known as Talk Therapy), Cognitive Behavioral Therapy (CBT), are Dialectical Behavioral Therapy (DBT) are all modes people can engage in to treat their conditions more fully; as any decent psychiatrist and/or psychologists would recommend one of these treatments to work alongside medication, not as a supplement for it. My own doctor has increased my understanding of my conditions and treatments by using a simply pie chart that shows all sides as being of equal import: proper medication or medication cocktail; the appropriate class of therapy; and a healthy lifestyle where one is not isolated and sedentary, but working toward getting out of the house (particularly if Agoraphobia is a problem, as it has historically been for me); finding and maintaining a healthy diet; and sticking with exercise plans (e.g., from basic but relatively quick walk to an hour of yoga or more daily). When applying these three factors—medicine, therapy, and every day life—to my own Major Depression, Borderline Personality, Generalized Anxiety disorder, Chronic Insomnia, and PTSD, I have had a more nuanced understanding of what has happened to me, what is the result of it, and how to truly think and act better on the path toward remission. For me, DBT became my bedrock, and its philosophy really took hold as something I could effectively use—whether or not I am hospitalized (which was it was first introduced to me)—and find the structure in DBT, where people keep diary cards and emotion diary to document their days, nights, and overall moods, to be quite illuminating indeed.

Dialectical Behavioral therapy involves both group therapy (pictured here at McLean Hospital), individual therapy, and the use of a mood journal and diary cards. It is a highly effective form of treatment, eradicating 86% of BPD traits over a ten-year-period (when studied regularly and with commitment).

Dr. Marsha Linehan, a psychologist working at The University of Washington at St. Louis, invented DBT by combining standard structures of CBT regarding emotion regulation, and elements of Zen Buddhism, which would further assist with critical employing modes of mindfulness and radical acceptance. While initially created to aid those with Borderline Personality Disorder (and it still does), DBT is now used all over the world to help people with a variety of mood and personality disorders. It can be life and even paradigm changing when a patient maintains his or her hers, or is able to procure a therapist who extremely well-versed in Dialectical Behavioral therapy.

THE FOUR MODES OF THOUGHT

  • MindfulnessThis is one of the foundational elements of DBT, and uses the power of emotions as healing, with Buddhist philosophy operating as the model. It teaches those to remain “in the moment” and “in the now;” and how to non-judgmentally paying attention to what is currently happening, has occurred in the past, and may or may not occur in the future. Living one’s life mindfully is challenging, but patients must remember that this is usually the case in making real profess fulfilling progress. Understanding how Mindful should and does function includes assisting patients in realizing how it can be implemented in their life—also allows that person to better observe, describe, and effectively their lives more willfully and completely in the world stretched out before them.
  • Distress Tolerance: Myriad approaches to behavioral health studies altering distressing events/circumstances; rather, DBT helps teach patients how to best learn their own emotions, even if they are painful memories. This will become possible, as the study of Mindfulness interacts with and ultimately bolsters one’s Distress Tolerance skill sets. No one has a perfect life, and yet, we often judge ourselves incredibly harshly, as if we are supposed to live that way. This is where Distress Tolerance become especially remarkable as a mode of therapy. One is carefully taught, with understanding, how to distract one’s self from unpleasant emotions so they are better able to deal with them more productively later on.
    • Distraction & Acceptance:
    • Activities: Use positive activities you enjoy.
    • Contribute: Help out others or your community.
    • Comparisons: Compare yourself either to people who are less fortunate or to how you used to be when you were in a worse state.
    • Emotions (of other people): This can cause you to feel differently (+) by provoking your sense of humor or happiness with corresponding activities. You can co-apt with your allies to aid each other in getting through difficult times and challenges.
    • Push Away: Temporarily put your situation out of your mind by putting something else (+) temporarily in its place.
    • Thoughts: Force yourself to be mindful and think about something else; something more helpful and productive.
    • Sensations: Do something that results in an intense feeling other than what you are presently feeling, such as taking a refreshing shower with nice-smelling products.
    • Remember to self-soothe in most of high distress, so you can tolerate them better, and reflect meaningfully and honestly at a better time.
    • Improvements In Skill Can Improve The Moment:
    • Imagery: Imagine relaxing scenes where things are going well, or other things that please you surround you.
    • Meaning: Try to find some purpose or meaning in what you are feeling.
    • Relaxation: Take time out of the day to relax your muscles, breathe deeply, and use self-soothing activities. This may also include prayer if one is religious. If not meditation and/or yoga can be extremely useful, as can simply chanting a personal mantra.
    • One thing in the moment: Focus all of your attention on what you are doing right now, and mindfully keep yourself in the present.
    • Vacation: Take a break from your daily stressors for a short period of time.
    • Encouragement: You are your own best cheerlead, so go ahead a cheerlead yourself in a way. Tell yourself, over and over again, that you can and will make it through this.
    • Pros & Cons: Conceive of the positive and negative components about not tolerating stress? What is the outcome? Surely less effective and positive than if you had chosen to tolerate it! Don’t judge yourself or become overly critical of what happened (or did not), and trust yourself to be more mindful of utilizing your DBT skill set next time. Everything takes practice, and we can always improve our skills!
    • Radical Acceptance: Let go of fighting reality. It is was it is. Accept your situation for what it is. Radically accepting something doesn’t mean you have to approve of or like the outcome: it means to let go of fighting something you can’t change, and living for the moment, for it is the only way to truly live. Don’t forget to Turn Your Mind toward a state of acceptance in these difficult times, and confidently carry on.
    • Over-Willfulness vs. Willfulness: Be willing and open to do what is effective, but remember not to let yourself be taken advantage of (and be aware if that pattern does emerge: DBT can help you change that characteristic as it so often results in immense pain). Let go of a willful stance which goes against acceptance, and keep your eye on the goal in front of you.
  • Emotion Regulation: For people suffering from mood and personality disorders, as well as suicidal ideation and self-injury/self-harm, the regulation of emotions is absolutely imperative. (Borderline Personality Disorder, in particular, adversely alters ones emotional state and increases their rate of [overly] emotional reactivity. Hence, studying DBT in its fullest sense, and paying particularly close mind to Emotional Regulation is of paramount importance.  Dialectical Behavioral therapy skills for emotion regulation include:
    • Identify and label emotion
    • Identify obstacles to changing emotions
    • Reduce vulnerability to emotion mind
    • Increase positive emotional events
    • Increase mindfulness in current emotions
    • Use opposite action skill
    • Apply distress tolerance techniques
    • Story Of Emotion: What You’re Feeling & Why
    • Understand the prompting event/trigger
    • Interpretation of the event
    • Body sensations
    • Body language
    • Action urge
    • Action
    • Emotion name, based on the list you created in Emotional Regulation when you identified and labelled your emotions.
    • Please Master: What You’re Feeling & Why
    • Physical Illness: If this applies to you, get proper treatment ASAP!
    • Eating: Making sure to eat a proper, healthy diet, and eat in moderation (i.e., not out of “boredom,” or “depression”).
    • Avoid mood-altering drugs: Take prescription medication as directed by your doctor, and try to stay away from illegal drugs, as they could interfere with your treatment.
    • Sleep: Be sure to regulate and balance your sleep schedule, and don’t sleep too much or too little. A maximum of eight hours of sleep is recommended nightly, though some people require less and some require more.
    • Exercise: It is essential to get in a good, effective workout, as this bolsters your body’s natural endorphins, and also aids with sleep issues.
    • Mastery/Building Skill Sets
    • Opposite Action:  This skill is best utilized when you have an unjustifiable emotion—one that doesn’t belong/shouldn’t result from the situation. Try to do the opposite of how you would normally react to resist your urges in a crisis moment. It is a tool to unearth unwanted emotions and replace them with more nuanced, appropriate, and healthy ones (i.e., instead of self-injuring, hold a frozen orange or an ice cube).
    • Problem Solving: When your emotions are justifiable and you need to problem-solve, this skill can help you do it in the most effective way possible. It is important to remain calm, and use skills such as Emotion Regulation.
    • Letting Go Of Emotional Suffering: It is okay to experience your emotions, but you also must be cognizant of accepting them, and then letting them go. Not doing so will not aid in problem solving; it will only cause unnecessary pain and suffering.
  • Interpersonal Effectiveness: This skill set has several components; the first can be recalled using the acronym DEARMAN (is about acquiring something); the second GIVE (regards giving something); and the third FAST (regards retaining self-respect). This includes asking for ones needs, saying no, and ultimately coping with interpersonal conflict. The module is focused on instances when the objective is to alter something, and/or resist changes someone else is trying to make. Essentially, Interpersonal Effectiveness teaches proper conflict negotiation, in which the relationship is not damaged, but neither is the person’s self-esteem. This can be especially challenging for people with BPD, and thus also extremely useful!
    • DEARMAN
      • Describe your situation.
      • Express why this is an issue and how you feel about it.
      • Assert yourself by asking clearly for what you want.
      • Reinforce your position by offering a positive consequence if you were to get what you want.
      • Mindful of the situation by focusing on what you want and ignore distractions.
      • Appear confident even if you don’t feel confident.
      • Negotiate with a hesitant person and come to a comfortable compromise on your request.
    • GIVE
      • Gentle: Use appropriate language, refrain from utilizing verbal or physical attacks; do not engage in put-downs; avoid sarcasm unless you are certain the other person is comfortable with it; and remember to be courteous and non-judgmental.
      • Interested: When the person with whom you are speaking is talking about something, act interested in what they are saying. Remember to use eye contact, ask questions, and otherwise be present and engaged.
      • Validate: Show you understand a person’s situation and desires, and sympathize with them. (This does not mean to falsely empathize, so don’t worry!). Validation can be shown in many forms, and thus your tactics will variety depending on with whom you’re interacting, but most important, remember that validation can be expressed through words, body language, and facial expression.
      • Easy Manner: Remain calm and comfortable during conversation. If appropriate, use humor and smile.
  • FAST
    • Fair: Be fair to both yourself and the other person.
    • Apologize: DO NOT apologize more than once for what you have done ineffectively, or for something which was not effective! Due to internal and toxic self-shaming, people with BPD tend to over-apologize; this is unhealthy for everyone involved.
    • Stick To Your Values: Stay true to who you are, what you believe in, and stand by it. Do not allow others to manipulate you into doing things that are against your system of values.
    • Truthful: Don’t lie. Lying will only pile up and damage relationships and, ultimately, your self-respect.
And remember: be kind to and gentle with yourself! It is very challenging, for anyone, to master these skills, but in time, it is my great hope you will find they’ve made a demonstratively positive difference in your life, as they have in mine.


Extremely Helpful DBT Skill-Building & Workbooks:

Marsha Linehan, Skills Training Manual For Treating Borderline Personality Disorder, The Guilford Press: New York, NY, 1993, 180 pages.

Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley, Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance, New Harbinger Publications: Oakland, CA, 2007, 248 pages.