Dialectical Behavior Therapy (DBT)

DBT was developed at the University of Washington by Marsha Linehan, PhD, who found that none of the available treatments were helpful in treating clients who were chronically suicidal and self-harming.  Her book, Cognitive-Behavioral Treatment of Borderline Personality Disorder, was first published in 1993, and since that time, therapists and researchers have found more and more applications for DBT, including substance use disorders, PTSD, eating disorders, and mood disorders.  DBT is now used in psychiatric inpatient units, outpatient mental health settings with adults and adolescents, residential programs, partial hospitalization programs, and intensive outpatient programs.  Extensive research has found that DBT reduces self-harm, suicide and suicide attempts, and hospitalizations and helps people to regulate their emotions.

DBT treatment is based on the assumption that the difficulties people develop managing their emotions and behavior are due to the interactions between an emotionally vulnerable individual and an invalidating environment.

An emotionally vulnerable person experiences high emotional sensitivity (may react to things others do not), high emotional reactivity (emotional experiences feel very intense), a slow return to emotional baseline (it takes a long time to feel calm again), and impulsivity (acting quickly on emotional urges).  Being emotionally vulnerable is not good or bad--it is a temperament some people are born with that may require more skills to manage in some environments.

Invalidating environments are environments in which one's emotional responses or sense of reality are responded to as if they are not real or important or are due to something wrong with the person having these responses.  Such environments can reward behavior, like angry outbursts, that can be problems in other parts of life and expect that people achieve goals without any help.  Invalidating environments vary: some are abusive, while others reflect an environment trying to do too much with too little support or resources.  Devaluing certain groups of people via systems of oppression creates an invalidating environment.  The invalidating environment we all share is life; even in the happiest of lives, there are moments of invalidation.

In environments in which their emotions are reflected as valid and they learn skills to manage them, emotionally vulnerable people can thrive.  Mildly invalidating environments may be tolerated by people who are less emotionally vulnerable.  The troubles arise when there is not a good fit between the person and their environment.  For particularly emotionally vulnerable people, many environments can feel invalidating, while in particularly invalidating environments, almost anyone would have difficulty.

A dialectical world view is one that aims to reduce the rigid relationships we may have to our thoughts, emotions, and physical sensations as well as what happens around us.  Dialectics focuses on finding balance rather than taking a position and refusing to change, not to invalidate ourselves but to reduce our own emotional suffering.  When we talk about dialectics, what we means is that we look for commonalities between opposites, understand change as the only constant, and understand that we all influence each other.

If you are wondering if dialectics are related to dialects, they have a common root word, dialektikos, which is Greek for conversation or discourse.

When we find ourselves frustrated with ourselves or others, we can become critical and punishing. Behaviorism is integrated into DBT to judge ourselves less and to do what will help us grow: set goals and encourage ourselves as we work toward them. The behaviorism skills in DBT can apply to relationships with others, too; we are more likely to enjoy the relationships we have if we reinforce behavior we do want from others rather than punishing them when they do something we do not like.

DBT has approximately 85 skills grouped into four modules:

1. Mindfulness Skills to be present with intention, without judging or clinging to some things and pushing away others

2. Distress Tolerance Skills to survive crises and accept difficult realities as real

3. Emotion Regulation Skills to help us notice, name, and regulate our emotions as well as ways to increase joy, live our values, and reduce mood swings

4. Interpersonal Effectiveness Skills to help us to have more confidence in asking for things or saying no as well as how to invest in relationships--including our relationship with ourselves.

DBT Diary Cards are a self-monitoring tool to help you track your urges to engage in behavior you want to avoid, whether or not you acted on these urges, emotional experiences, events of your day, and skills that you used to cope.

As with all self-monitoring tools, DBT Diary Cards tend to increase the behaviors you wish to increase, e.g., healthy coping skills, and to decrease behaviors that you wish to decrease.  Most clients find that, after the first week of using a diary card, they find that it only takes 1-2 minutes to complete per day.  To download the version of the DBT diary card that I use in my practice, please click on the link below.