The dialectical behavior therapy is a type of psychological therapy that involves many aspects from the cognitive behavior therapy which includes the behavior therapy, along with the cognitive restructuring and many other interventions to help patients with borderline personality disorders, or also known as emotional instability disorders.
But it is also scientifically proven that dialectical behavior therapy can help in the treatment of other mood disorders such as splitting in personality disorder, suicidal behaviors, as well as the changes in behavioral patterns such as self harm by other means, and substance abuse.
What is DBT then?
In psychological terms, DBT stands for Dialectical Behavior Therapy, both DBT and Dialectical Behavior Therapy are used interchangeably.
How dialectical behavior therapy different than cognitive behavioral therapy?
Even though the dialectical behavior therapy shares many characteristics from cognitive behavioral therapy or CBT, it possesses several unique elements with the sole purpose of constituting dialectical behavior therapy (DBT). According to research conducted by Dr. Alexander Chapman, some of these fundamentals consist of:
- Helping the five functions of treatment
- The bio-social theory and focusing on emotions in treatment
- A consistent dialectical philosophy
- Mindfulness and acceptance-oriented interventions
Primary goal of dialectical behavior therapy
The primary goal of the dialectical behavior therapy is to help patients identify and change negative conduct patterns while striving to build positive changes in their living by giving the individuals tools to accept, cope and change unhealthy behaviors.
This therapy was born as the Marsha Linehan’s hard work to create an efficient treatment for multi problematic, suicidal women in the late 1980’s. After she and her group realized that cognitive-behavior therapy (CBT) alone did not work well, as it was expected to work for many patients, especially for borderline personality disorder (BPD).
Throughout time, dialectical behavior therapy has been used to aid patients who suffered from borderline personality disorder (BPD) and substance use disorders (SUD), individuals who present symptoms for binge-eating disorder, depressed elderly patients and some cases of post-traumatic stress disorder (PTSD).
Components of the dialectical behavior therapy
Dr. Linehan laid out the basis of the dialectical behavior therapy and her team with a combination of cognitive-behavior therapy characteristics to develop a new and unique therapy to fit the needs of borderline personality disorder (BPD).
This therapy is based on a philosophical process called dialectics. The foundation behind the dialectic’s definition is the principle that everything is composed of opposites. In this case, it is about opposite ways of therapy which are acceptance and change. The idea was to bring them together to obtain better results instead of applying either of them one at a time.
With the help of dialectics system, Linehan created three basic assumptions:
- All the things are connected within each other
- Change in life is constant and inevitable
- The opposites can be used to create a more approximate version of the truth
During dialectical behavior therapy (DBT), the patients and therapist decide to work and try to resolve the apparent contradiction between self acceptance and change, so the individuals can cause or bring positive changes in their lives.
There are three basic components in dialectical behavior therapy:
1. Individual therapy
With the help of dairy cards – a daily filling out format where patient and therapist can track over 40 emotions, urges, toxic behaviors or skills such as lying, self injury or self respect etc. The person and their therapist discuss all the possible behaviors appear within a week to treatment as it follows:
First place for self-injurious and suicidal behaviors which can translate to life threatening behaviors.
Secondly, other related behaviors that are interfering with the efficacy of the treatment also known as therapy interfering behaviors such as emotional regulation, distress tolerance, and interpersonal effectiveness.
Thirdly, the quality of life issues which means starting to work towards improving their general lives by enhancing their relationships and self esteem.
Fourth or lastly promoting more joy by increasing the relational connection.
In this stage of the therapy, patient and therapist work with the acquisition of new skills and adapting them to their daily challenges.
2. Group skills training
In this part, a group of patient has to regularly meet once a week in sessions of two or two and a half hours to learn how to use specific skills by making homework assignments as well as role playing new ways to interact or create bonds with people.
3. Phone coaching
This stage was designed for helping the patients to the adaptation of their new set of skills in their daily lives. These sessions are limited and focused solely on the skills.
It is also related to highly stressful situations that may be presented at any given moment and the aid for helping them using new skills with proper guidance by a therapist through out the situation.
The four modules of the dialectical behavior therapy
Dialectical behavior therapy uses these 4 strategies (skills) or main modules to help the patients to effectively change their behavior:
1. Core mindfulness
This is one of the core ideas of dialectical behavior therapy (DBT). Considerably it is the primary stone of this therapy since it can help the individuals to accept and tolerate their strong emotions, to face challenging behaviors, habits or uncomfortable situations.
It focuses on teaching the patients to stop and live in the moment. The concept behind is the use of mindfulness and meditative exercises to develop the capacity to pay attention in trying to live the present moment with no judgments by letting the emotions, feelings, and experiences happen fully but always under a perspective.
When practicing mindfulness people learn to pay attention to what’s going on inside themselves (feelings, thoughts, and impulses) as well as what’s outside them that can be perceive with their senses touch, smell, sight, taste, and sound and approach them in a nonjudgmental way thus helping them to apply healthy coping skills for them to deal with emotional pain.
With mindfulness, you will get to remain calm and avoiding engaging negative behavior patterns.
Inside core mindfulness you can find the next main skills to develop:
Acceptance and change
This is the first step in dialectical behavior therapy. Once the patient feels comfortable with their therapist, the first dialectic tool to appear is the acceptance and change principle.
This principle involves the meaning of radical acceptance which means embracing all the situations faced daily, whether positive or negative without any judgment. This instrument uses mindfulness and emotional regulation skills to make important changes in the subject’s lifestyle.
When beginning the radical acceptance process, the therapist will have 5 states to review the patient and determine their evolution. These stages are:
- Precontemplation – This stage happens when the patient begins therapy by being unaware of the problem.
- Contemplation – It is the second step and consists of the patient’s realization of their illness. There is no need for an action.
- Preparation – The third step consists of the moment when the person prepares to move or to take action to heal or move forward. These actions can be researching on the topic or contacting a therapist.
- Action – The four-step involves taking action by going to therapy and beginning dialectical behavior therapy (DBT).
- Maintenance – This is the final step of radical acceptance and involves strengthening their willingness to change to avoid relapses.
“What” skills
These are a set of instruments for often use when practicing mindfulness and they should be done in order at one at the time.
These activities consist of:
- Observe – This happens when the patient decides to pay attention to what’s happening inside or outside of them with no judgment.
By using this tool, the person can objectively observe what’s going on in any given situation.
Dialectical behavior therapy often uses the term of developing a “Teflon mind” which consists of the ability to cultivate a strong mindset that allows feeling and thoughts to pass by without sticking. - Describe – Consist of putting into words what the patient has observed within or outside themselves. This has to be done without judging and by unfolding all the information gathered with the use of all the 5 senses to comprehend better the surrounding environment.
- Participate – It happens when you can fully compromise the activity or situation happening by involving all your senses in the present moment.
“How” skills
These set of skills are used to better describe the observance and participation when practicing mindfulness. These are divided into three aspects:
- Non-judgmental – In this action, the individual has to describe the situations as facts and not as terms of positive or negative circumstances.
These judgments may cause an emotional alteration which is why they need to be avoided. By being nonjudgmental you will describe or make points objectively without adding a judgment which may bring disagreements. - One-mindfully – This tool means to focus only on one thing. With this, patients can focus “one thing at the time” thus avoiding carried away by emotions.
- Effectively – It limits the patient to just doing what effectively works for any situation. In difference of the “what” skills, the “how” skills can be all done at the same time.
2. Distress tolerance
This is another column of dialectical behavior therapy that differences it from other approaches. This pillar consists of learning to accept yourself and current situations thus making bearing pain more efficient and skillfully.
Dialectical behavior therapy uses distress tolerance as another side of mindfulness techniques and it can also be used to deal with death of a loved ones, appearance of a serious illness, loss of a job, terrorist attacks and other traumatic events.
Distress tolerance means the ability to accept in a nonjudgmental environment oneself and the situation without the need of labeling them with approval or resignation. Is to overcome those painful moments and recognizing their impact in our lives instead of hiding from them.
To achieve this, you need to develop the following dialectical behavior therapy techniques:
TIP skill
This one is the fastest and most efficient way to distress. People can use this skill when they feel emotionally overwhelmed and willing to self-harm.
TIP comes from the acronym of the steps of the skill:
- Tipping the face’s temperature with cold water
- Intense exercising for at least 20 minutes
- Paced breathing along with muscle relaxation
Distraction
This can be made by using the ACCEPTS acronym in this way:
- Activities – By making positive activities that they can enjoy
- Contribute – Helping others or in their community
- Comparisons – Comparing yourself with people in worse scenarios thus feeling thankful
- Emotions – Causing a change of humor by making activities to provoke happiness or joy
- Push away – Put in the back of your mind stressful situations temporarily
- Thoughts (other) – Pushing yourself into thinking of something else
- Sensations (other) – Do something different than what you are feeling, preferably causing another intense feeling
Self soothing
In this skill, you need to be self-comforting, self-nurturing, kind, and gentle with yourself. This tool is used in the moment of intense distress or sentimental agitation and can consist of the practice of activities that help you to calm down such as listening to music or playing an instrument.
Improving the moment
This is another skill that can be used in tense situations for calming your mind. Use this acronym to follow the steps:
- Imagery – use your imagination to create relaxing scenes, other scenarios or things going well.
- Meaning – find the purpose of what you are experiencing at the moment
- Prayer – you can pray or chant a mantra to relax
- Relaxation – use relaxation techniques to calm down your muscles and breathe deeply
- One thing in the moment – focus your attention on the present.
- Vacation (brief) – take a break from the situation briefly
- Encouragement – cheering yourself by telling you that you can overcome a certain situation with optimism
Thinking of pros and cons
Putting things in perspective by comparing the pros and cons of any given situation.
3. Emotional regulation
This is a set of skills that will help you to navigate through rough emotions or situations. Dialectical behavior therapy (DBT) tools for this purpose include:
- Spot and label emotions
- Recognize obstacles to shifting emotions
- Diminish susceptibility to emotion mind Raise positive emotional actions
- Add mindfulness to current emotions
- Take the opposite action
- Apply distress tolerance techniques
The emotional regulation theory bases in the statement that intense emotional response is triggered for memories of troublesome experiences thus creating a conditioned response.
The patient can change that by learning to manage them in four stages:
Understanding and naming emotions
Here, the patient has to focus on naming and recognizing their feelings. This stage is directly related to mindfulness and also consists is exposing the patient to their emotions.
Changing unwanted emotions
In this stage, the therapist focuses on using coping skills such as opposite-reactions, fact-checking, and problem solving with the main goal of distressing and regulating their emotions.
Reducing vulnerability
At this stage, patient learns many coping skills that will help them to improve their handle of emotionally stressful situations in the future.
Managing extreme conditions
In this stage, the patient focuses on using mindfulness techniques to remain calm and alert during an intense situation.
If the patient needs to identify or label their emotions, they can use the following strategies:
The story of the emotion – with this, you will better understand the emotion you are feeling at the moment. To get this done, you need to check the following steps:
- Prompting event
- Explanation of the event
- Verbalize body sensations
- Realize body language
- Prevent the action urge
- Take conscious action
- Name the emotion, based on previous items
Opposite reaction – this happens when the patient decides to do the opposite of what the rushed feeling is telling them what to do. It can be done by taking an unwanted emotion from the equation and replacing it with an opposite one.
Problem solving – when the emotion is justified by other techniques, you can use the problem-solving skill in trying to resolve the situation first hand. It has to be used with a combination of other coping and distress techniques.
4. Interpersonal effectiveness
This consists of a set of tools to help the individual to become more assertive in their social interactions. It includes several effective tactics for asking for what the other one need, ways to say no, and coping with interpersonal conflict.
One example of these tactics is the GIVE acronym. Use the acronym GIVE if you want to develop positive relationships and communication:
- Gentle – by using appropriate language, try not to judge, verbally or physically attack or using sarcasm on others
- Interest – show interest in what the other is saying by maintaining eye contact, asking questions and avoiding cell phone use
- Validate – try to show empathy for the other person or their situation by validating them with comfort words
- Easy – try to be calm and joyful during a conversation
Effectiveness of dialectical behavior therapy
Dialectical behavior therapy has been scientifically proved to aid for people under these medical conditions:
1. Para suicidal patients with Borderline Personality Disorder
For para suicidal borderline personality disorder (BPD) patients, dialectical behavior therapy or DBT delivers excellent results in reduction of para suicidal behavior compared with other control conditions according to several modern researches.
Dialectical behavior therapy has been proved to consistently reduce the frequency and medical severity of para suicide, inpatient hospitalization days, anger, and enhancing social functioning for patients.
2. Women with BPD and substance use disorders
This other group is one of the most benefited from DBT or dialectical behavior therapy.
One study showed that patients treated with dialectical behavior therapy showed greater reductions in drug use during the 12 months treatment and through the four-month follow-up period; they also had lower dropout rates during treatment.
3. Borderline personality disorder
Dialectical behavior therapy a.k.a DBT has been proved to enhance the quality of life in women suffering from borderline personality disorder (BPD).
In a study done by a Canadian University in 2009 with 180 adults, and separating in two groups of 90 individuals each for a treatment period of 41 weeks showed an average important decrease of suicidal events as well as self-injurious ones (between 48% and 77% of reduction respectively).
4. Other clinical populations and problems
Dialectical behavior therapy can treat conditions such as eating disorders and depression in elderly patients.
For women with binge eating disorder, Dialectical behavior therapy to treat these patients demonstrated greater improvements in bingeing, body image, eating concerns, and anger by reducing an 86% of binge eating at the end of the study, although keeping a 56% of effectiveness after the trial ended.
In relation to depression in elderly patients a study made for patients over 60 years old who met criteria for personality disorder, were treated with modified dialectical behavior therapy plus antidepressant medications.
A large number of these patients were in remission from depression at post-treatment in the follow-up six months period.
Conclusion
Dialectical behavior therapy, which in short also known as DBT is a psychological therapy derived from cognitive behavior therapy, initially designed to help suicidal women.
Although dialectical behavior therapy has many similarities with cognitive behavioral therapy, but there are some critical and unique properties divided in modules and components, which differentiate dialectical behavior therapy significantly from other behavioral therapies.
Dialectical behavior therapy soon became effective for para suicidal women with borderline personality disorder. With time it also proved to be an useful therapy for treating other borderline disorders, substance use disorders, and depression.
