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- Herausgeber: John Wiley & Sons
- Kategorie: Ratgeber
- Sprache: Englisch
Keep calm, be skillful--and take control! Dialectical Behavior Therapy (DBT) is one of the most popular--and most effective--treatments for mental health conditions that result from out-of-control emotions. Combining elements of Cognitive Behavior Therapy with Eastern mindfulness practice, DBT was initially used as a powerful treatment to address the suffering associated with borderline personality disorder. It has since proven to have positive effects on many other mental health conditions and is frequently found in non-clinical settings, such as schools. Whether you struggle with depression, anger, phobias, disordered eating, or want to have a better understanding of emotions and how to focus and calm your mind, DBT practice serves the needs of those facing anything from regular life challenges to severe psychological distress. Written in a no-jargon, friendly style by two of Harvard Medical School's finest, DBT For Dummies shows how DBT can teach new ways not just to reverse, but to actively take control of self-destructive behaviors and negative thought patterns, allowing you to transform a life of struggle into one full of promise and meaning. Used properly and persistently, the skills and strategies in this book will change your life: when you can better regulate emotions, interact effectively with people, deal with stressful situations, and use mindfulness on a daily basis, it's easier to appreciate what's good in yourself and the world, and then act accordingly. In reading this book, you will: * Understand DBT theory * Learn more adaptive ways to control your emotions * Improve the quality of your relationships * Deal better with uncertainty Many of life's problems are not insurmountable even if they appear to be. Life can get better, if you are willing to live it differently. Get DBT For Dummies and discover the proven methods that will let you take back control--and build a brighter, more capable, and promising future!
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Veröffentlichungsjahr: 2021
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DBT For Dummies®
Published by: John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030-5774, www.wiley.com
Copyright © 2021 by John Wiley & Sons, Inc., Hoboken, New Jersey
Published simultaneously in Canada
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Library of Congress Control Number: 2021935362
ISBN 978-1-119-73012-5 (pbk); ISBN 978-1-119-72567-1 (ebk); ISBN 978-1-119-73016-3 (ebk)
DBT For Dummies®
To view this book's Cheat Sheet, simply go to www.dummies.com and search for “DBT For Dummies Cheat Sheet” in the Search box.
Table of Contents
Cover
Title Page
Copyright
Introduction
About This Book
Foolish Assumptions
Icons Used in This Book
Beyond the Book
Where to Go from Here
Part 1: The Nuts and Bolts of DBT
Chapter 1: Entering the World of DBT
Looking at the Main Pillars of DBT
Getting an Overview of DBT’s Treatment Modes and Functions
Focusing on the DBT Theoretical Framework
Checking Out the DBT Stages of Treatment
Surveying DBT Skills
Walking through the Mechanics of DBT
Treating Specific Conditions with DBT
Chapter 2: Understanding Dialectical Behavior Therapy
Beginning with the Biosocial Theory
Focusing on the Functions and Goals of a Comprehensive Treatment
Checking Out Modes of Treatment
Incorporating Dialectics
Chapter 3: Accepting Multiple Points of View
Questioning Your First Reaction
Expanding Your Perception
Looking at Yourself with Friendly Eyes
Chapter 4: Moving from Impulsive to Spontaneous
Distinguishing Impulsivity and Spontaneity
Moving Beyond Your First Reaction
Opening Up
Transforming Negatives into Positives
Part 2: Gaining Understanding
Chapter 5: Understanding Your Emotions
Recognizing How You’re Feeling
Confronting Disproportionate Reactions
Identifying and Handling Problem Areas
Chapter 6: Understanding Your Behaviors
Being Aware of How Your Emotions Manifest in Action
Identifying and Handling Emotional Triggers
Tying Specific Behaviors to Specific Reactions
Chapter 7: Understanding How You Think
Tapping into Your Self-Talk
Looking at Your Reactions
Chapter 8: Understanding Your Relationships
Recognizing Relationship Dynamics
Enhancing Communication
Making Room for More Possibilities
Part 3: Exploring DBT Skills
Chapter 9: Thinking about Mindfulness
Exploring Your Own Mind
Understanding Types of Mindfulness
Realizing the Benefits of Mindfulness
Chapter 10: Regulating Your Emotions
Turning the Keys of Emotion Regulation
Being Your Own Emotional Support
Chapter 11: Building Your Distress Tolerance
Managing Difficult Moments with Crisis Survival Skills
Recognizing That Everything Has a Cause
Curbing Impulsive Behavior
Doing Your Own Crisis Management
Chapter 12: Increasing Your Interpersonal Effectiveness
Before You Begin: Being Aware of Obstacles
Mastering the DEAR MAN Skill
Practicing the Art of Validation
Communicating with GIVE Skills
Staying True to Yourself with the FAST Skill
Combining GIVE and FAST
Putting It All Together
Chapter 13: Walking the Middle Path
Finding the Balance
Embracing Cooperation and Compromise
Part 4: The Mechanics of DBT Therapy
Chapter 14: Exploring Therapy Basics
One on One: Individual Therapy
All Together: Group Therapy
Time to Connect: Phone Coaching
Chapter 15: Embracing Dialectics
In the Beginning: Stumbling onto Dialectics
Thinking Dialectically
Looking at the Main Dialectical Dilemmas Tackled in Treatment
The Dialectical Dilemmas of Parenting: Walking the Middle Path
Understanding Therapist Dialectical Interventions
Chapter 16: Structuring the Environment
Adding Structure to Two Different Environments
Addressing a Problem in Five Ways
Building a Framework
Structuring Individual Sessions
Putting Structure in Different Contexts
Chapter 17: The Therapist Consultation Team
Joining a Consultation Team
Sticking to the Agenda
Chapter 18: Tracking Your Experience
Keeping a Daily Diary Card
Analyzing Your Behavior
Chapter 19: Gaining and Keeping Motivation
Having Motivation for Therapy
Increasing Motivation
Maintaining Motivation
Part 5: Putting DBT into Action for Specific Conditions
Chapter 20: Building Mastery for Mood and Personality Disorders
Addressing Borderline Personality Disorder
Managing Your Moods
Alleviating Anxiety
Chapter 21: Taming Trauma
Understanding the Basics of DBT PE
DBT-PTSD: Exploring an Alternative Model
Digging into the Dilemma of Dissociation
Chapter 22: Tempering Addictions
A Word about Dopamine
Working through Substance Dependence
Overcoming Eating Disorders
Gaining Ground on Body Dysmorphic Disorder
Getting a Grip on Behavioral Addictions
Chapter 23: Dealing with Counterproductive Behaviors
Tackling Self-Invalidation
Handling Self-Hatred
Balancing Solitude and Connectedness
Part 6: The Part of Tens
Chapter 24: Ten Mindful Practices
Observe an Itch
Observe the Urge to Swallow
Observe Your Hands
Observe Your Breath by Ladder Breathing
Describe a Social Media Post
Describe a Difficult or Painful Emotion
Describe the Sounds around You
Participate in Standing on One Foot
Participate in Writing with Your Non-Dominant Hand
Participate in Driving a Car
Chapter 25: Ten Ways to Live an Antidepressant Life
Engaging in Exercise
Trying Meditation
Eating a Less Refined Diet
Being Careful with Alcohol and Various Drugs
Getting Enough Sleep
Maintaining Social Interaction and Connection
Adding Recreation and Relaxation to Your Routine
Accessing Green Space and the Environment
Taking Care of Pets and Other Animals
Making Time for Faith and Prayer
Chapter 26: Ten Myths about DBT
Myth: DBT Is Used Only with People with Borderline Personality Disorder
Myth: DBT Therapists Teach Skills from a Manual; It’s Not a Real Therapy
Myth: DBT Takes Years Before You Feel Better
Myth: DBT Is a Suicide Prevention Therapy
Myth: If No Other Therapy Has Helped, DBT Won’t Either
Myth: Once You Start DBT, You Need to Continue It Forever
Myth: You Have to Accept Buddhism to Do DBT
Myth: DBT Is a Cult
Myth: There Is Very Little Evidence That DBT Works
Myth: DBT Isn’t Interested in “Root Causes” of Mental Illness
Index
About the Authors
Advertisement Page
Connect with Dummies
End User License Agreement
List of Illustrations
Chapter 18
FIGURE 18-1: A typical diary card.
FIGURE 18-2: A detailed list of skills.
Guide
Cover
Title Page
Copyright
Table of Contents
Begin Reading
Index
About the Authors
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Introduction
In our professional experience, at no other time have we seen more of a demand for compassionate, effective, and comprehensive mental health care than we did in the strange year of 2020. The mental health toll caused by the isolating impact of the COVID-19 pandemic, the financial uncertainties of the economy, the divisive polarization of social justice causes, and the doubt and suspicions magnified by political extremes has impacted those without mental health issues, significantly impacted those with mental health issues, and even affected mental health practitioners. We are, after all, human beings whose brains respond to stress, strong emotions, and lack of connection.
We all need to take care of ourselves, and we don’t have time to spend years contemplating our lives. The changes you make today will reverberate throughout the rest of your life. Now is the time to start behaving in ways that are consistent with your values and your aspirations. Of course, you need the help of others — even the most powerful of quarterbacks cannot win without a supportive team — but you can also take charge of some of your own self-care. You don’t need the blessing of others to start changing your behaviors, by eating healthier food, exercising more regularly, getting to bed on time, reducing your alcohol intake, and practicing some meditation every day. And then, when you’re a healthier person, you bring a more skillful version of yourself to your life and to the relationships that you care about.
We have told our patients, friends, families, and colleagues that DBT — dialectical behavior therapy — is not just for our patients but is also a life enhancer for everyone. When we practice DBT, we are better able to take care of ourselves and our relationships, we are more compassionate, and we make less judgmental assumptions. We don’t say these things simply because we authored this book, but because we have seen the benefits of DBT in our personal and professional lives.
About This Book
DBT For Dummies is a book for our time. The world in 2020 — when we wrote this book — was full of the most unexpected of challenges. There was a global pandemic, a contentious election, and demonstrations that highlighted significant divisions within our communities. These are experiences that demand the most of us, and yet can also bring out our weaknesses and struggles.
For those who already fight against underlying mental health conditions, the need to be able to regulate, connect effectively, tolerate difficult moments without sinking deeper into despair, and pay attention to the present moment, each other, and ourselves makes the need for the skills in this book timely and essential. These are skills that, if learned, used, and practiced on a regular basis, will get us not only through this moment but through all future moments, whether or not they are filled with uncertainty.
Almost everything you need to know about DBT is in this book, whether you’re new to the therapy or an expert practitioner looking for new ideas. We want to be very clear that this book is no substitute for expert therapy. Reading it will inform you and give you some good ideas as to what to do, but it takes a therapist skilled in DBT to help you if you’re struggling.
Along our own journey with DBT, we’ve had many patients tell us that they did DBT before and that although we use many similar terms and practices, what we did was different. Many of our protocols will be identical to those of other DBT therapists. However, because DBT is not only protocol-based but also principle-driven, there is also an art to DBT, and that is the way in which it is delivered. Many of the ideas in this book come directly out of our own clinical practice, and different therapists may apply the therapy differently.
As with all For Dummies guides, you won’t have to read this book from start to finish as you would so many other books. If the only thing you’re interested in is how to practice emotion regulation, how to use mindfulness to improve your relationships, or how to apply DBT to a specific mental disorder, the information is here, easily found, and ready to be read and comprehended in minutes.
A quick note: Sidebars (shaded boxes of text) dig into the details of a given topic, but they aren’t crucial to understanding it. Feel free to read them or skip them. You can pass over the text accompanied by the Technical Stuff icon, too. The text marked with this icon gives some interesting but non-essential information about some of the more technical procedures in DBT.
One last thing: Within this book, you may note that some web addresses break across two lines of text. If you’re reading this book in print and want to visit one of these web pages, simply key in the web address exactly as it appears in the text, pretending as though the line break doesn’t exist. If you’re reading this as an e-book, you’ve got it easy — just click the web address to go directly to the web page.
Foolish Assumptions
Dear reader, we make a few assumptions about you. No, you’re no dummy; however, you’re reading this book because you want a clearer, less jargon-filled understanding of dialectical behavior therapy. You may have some basic knowledge about the therapy, and you may have heard that it’s useful to treat certain conditions, but this book will offer a much clearer picture of this fascinating therapy.
We also recognize that no book is a substitute for expert therapy, and we assume that anyone who is in need of help will seek it out, even if they use this book as a guide for understanding. Finally, we assume that readers who are suffering might do so in ways that make it hard to learn new approaches. We value you tremendously and support you in your efforts to improve, despite the obstacles that life may have thrown at you.
Icons Used in This Book
We include some handy icons that you may notice in the margins of this book. They point you to certain types of information, so be sure you know which is which.
We include some text that tips you off into certain directions — this icon makes sure you notice. These aren’t substitutes for practicing the skills as they are intended, but they are reminders that might make it easier to remember a skill.
Although we’d like you to remember everything we say, we have seen time and again just how easy things are to forget. We will repeat things, because we know that repetition is a great way to learn, and if you tend to forget, if you see this icon, be sure to ingrain this information in your brain.
Just as we want you to remember everything we say in this book, and that we’d love for you to do everything we recommend, it’s possible (okay, highly likely) that you’ll only do half (okay, a quarter) of what we suggest. But to truly stay away from pitfalls that can create significant obstacles to your healing, you should heed any warnings that you see associated with this icon.
Just like any expert, we do have nuggets of knowledge that only some of our most persistent patients and DBT junkies could love. But we know that you may want to know more and delve deeper into subjects like neural pathways and brain chemicals. If these excite you rather than putting you to sleep, we welcome you to dive in with us. However, if you prefer, you can skip the information associated with this icon. This is the only icon that points you to information that you can skip if you prefer to.
Beyond the Book
In addition to the material in the print or e-book you’re reading now, this product comes with some access-anywhere goodies on the web. Check out the free Cheat Sheet for interesting information on what to expect from DBT, the components of DBT, and useful skills you’ll discover. To get this Cheat Sheet, simply go to www.dummies.com and search for “DBT For Dummies Cheat Sheet” in the Search box.
Where to Go from Here
At this point…browse! Check out the detailed table of contents and go straight to those chapters that grab your interest. This isn’t a novel that you need to read from start to finish. It’s more like when our children open up the fridge and take the things they want. If you’re totally new to DBT, though, we do recommend starting with Chapter 1.
As you understand more and more about DBT, and maybe even teach your therapist a thing or two, keep coming back to this book and discover more information, which will increasingly be accompanied by “aha” moments, and do let us know. We thank you for including us on your journey.
Part 1
The Nuts and Bolts of DBT
IN THIS PART …
Discover how DBT (dialectical behavior therapy) was developed.
Understand the components of a comprehensive DBT treatment.
Recognize the elements of a contemplative mindfulness practice as a core part of DBT, and figure out how to accept multiple points of view.
Interweave behaviorism into mindfulness practices to develop a complete therapy.
Chapter 1
Entering the World of DBT
IN THIS CHAPTER
Looking at the pillars, modes, and functions of DBT
Getting a handle on the DBT theoretical framework
Stepping through DBT’s stages of treatment
Considering core DBT skills
Seeing the mechanics of DBT
Using DBT to treat specific conditions
Entering the world of DBT (dialectical behavior therapy) is entering into a world that focuses on the philosophical process of dialectics, while also attending to the psychological process of behaviorism and change. Imagine entering into a therapy that tells you that everything is composed of opposites, that these opposites are all true, that everything changes except for change itself, and that the way out of suffering is to start by accepting that all of these things are true. This chapter introduces the basics.
Looking at the Main Pillars of DBT
DBT stands on three big philosophical and scientific pillars. These pillars are specific assumptions that hold the treatment together:
All things are interconnected.
Everything and everyone is interconnected and interdependent. We are all part of the greater tapestry of all things, a community of beings that supports and sustains us. We are also connected to our family, friends, and community. We need others; others need us.
Change is constant and inevitable.
This is not a new idea. The pre-Socratic philosopher Heraclitus said, “The only constant in life is change.” Life is full of suffering, but because change happens, change being the only thing of which you can be certain, your suffering will change as well.
Opposites can be integrated to form a closer approximation of the truth.
This is at the core of dialectics. A dialectical synthesis combines the thesis (an idea) and the antithesis (its opposite). In coming up with the synthesis of the two ideas, the process never introduces a new concept not found in either the thesis or the antithesis. Strictly speaking, the synthesis incorporates one concept from the thesis and one from the antithesis.
Check out Chapter 2 for more about DBT’s main pillars.
Getting an Overview of DBT’s Treatment Modes and Functions
DBT was originally developed by Dr. Marsha Linehan for the treatment of people who struggled with self-destructive and suicidal behavior, and it subsequently became the gold-standard treatment for the condition known as borderline personality disorder (BPD), which we review comprehensively in Chapter 20. The treatment appeals to many therapists and patients, not only because it is very helpful, but because it integrates four essential elements in a comprehensive treatment by addressing the biological, environmental, spiritual, and behavioral elements of a person’s struggle. It’s also unique in its focus on balancing the need for a person to change while being completely accepted for who they are in the present moment.
As you find out in Chapter 2, DBT delivers the treatment through four modes, and these four modes address the five functions of a comprehensive treatment.
The four modes of therapy
There are four modes of therapy, which are detailed completely in Chapter 14:
Individual therapy:
In this mode, a trained therapist works with you to apply newly learned skills to your personal life challenges.
Group skills training:
In this mode, together with a group of other patients, you’re taught new behavioral skills, you complete homework assignments, and you role-play new ways of interacting with others.
Phone skills coaching:
In this mode, you can call your therapist between sessions to receive guidance on coping with difficult situations as they arise.
Therapist consultation team meetings:
In this mode, your individual therapist meets with other therapists who are also providing DBT treatment. These meetings help therapists navigate difficult and complex issues related to providing therapy, and give them new ideas for what to do when they are stuck.
Chapter 17
goes into more detail on the consultation team.
The five functions of treatment
As you see in the previous section, DBT is a comprehensive treatment program. In this way, DBT is a collection of treatments, rather than a single treatment method conducted by a single therapist and a single patient. Any program, whichever you choose to do, should address five key functions of treatment (which are fully reviewed in Part 4):
Increasing your motivation to change:
Changing self-destructive and maladaptive behaviors can be very difficult, and it can be easy to become disheartened. Your individual therapist will work with you to make sure you stay on track and reduce any behaviors that are inconsistent with a life worth living. Within individual and group therapy, your therapist will ask you to track your behaviors and use skills coaching in order to achieve this goal.
Enhancing your capabilities:
DBT assumes that people who struggle either lack or need to improve several important life skills, including skills that help you regulate emotions, pay attention to the experience of the present moment, effectively navigate interpersonal situations, and finally, be able to tolerate distress.
Generalizing what you’ve learned in therapy to the rest of your life:
If the skills you’ve learned in group and individual therapy sessions don’t transfer to your daily life, then it’s going to be difficult to say that the therapy was successful for dealing with your problems.
Structuring your environment in order to reinforce your gains:
An important function is to make sure that you don’t slip back into maladaptive or problematic behaviors or, if you do, to make sure that the impact isn’t enduring. Structuring the treatment in a manner that promotes progress toward your goal is a way to do this. Typically, your individual therapist will make sure that all of the elements of effective treatment are in place for you. At times, they may intervene for you if you aren’t yet skilled enough to do so for yourself, with the understanding that such intervention is temporary until you have acquired the skills to manage.
Increasing your therapist’s motivation and competence:
Although helping people who come to therapy with multiple problems can be very rewarding for both patient and therapist, the behaviors that people present with can be very taxing for the therapist, and so the therapist needs help to stay in the game of DBT. This is where the DBT consultation team that you read about in the previous section comes in.
Focusing on the DBT Theoretical Framework
The practice of DBT relies on three central theories:
The biosocial theory: Dr. Linehan’s biosocial theory essentially states that people who struggle in regulating their emotions do so because of an enduring interaction between that person’s biological makeup — one that makes them more emotionally sensitive, more emotionally reactive, and slower to return to their emotional baseline — and what she termed the invalidating environment.
An invalidating environment is one where a child’s emotional experiences aren’t recognized as valid or tolerated by significant people in the child’s life. When this happens, and a child’s emotional experiences aren’t validated until the child has escalated emotionally and with high intensity, the child effectively learns that they have to escalate to be heard. When they get punished for expressing high emotions, the child might take their difficulties underground and try to regulate by using maladaptive behaviors such as self-injury. This, in turn, leads to even greater emotionality, as the child experiences shame and guilt. Flip to Chapter 2 for more about the biosocial theory.
Behavioral theory: The behavioral theory seeks to explain human behavior by analyzing the antecedents of the behavior. Antecedents are the events, situations, circumstances, emotions, and thoughts that preceded the behavior — in other words, the events that were happening before the behavior occurred — and the consequences of the behavior are the actions or responses that follow the behavior. It’s in understanding the elements that are causing behaviors to manifest — and then further understanding what keeps the behaviors going — that the behavioral theory is applied in order to reduce maladaptive behaviors and increase adaptive responses.
An important element to this theory is that maladaptive behaviors are maintained because a person lacks the skills for more adaptive functioning due to problems in processing emotions and thoughts, which is why there is such an emphasis on teaching helpful emotion regulation skills. We discuss regulating your emotions in Chapter 10.
The philosophy of dialectics:
Essentially,
dialectical theory
states that reality is the tapestry of interconnected and interwoven forces, many of which are opposing one another. It is the continuing synthesis of opposing forces, ideas, or concepts that defines dialectics.
Chapter 15
has more information on dialectics.
Checking Out the DBT Stages of Treatment
DBT consists of five stages of treatment, one of which is pretreatment:
Pretreatment:
This is the period of time when the person is making a direct commitment to themselves and their therapist to do DBT therapy. In this stage of pretreatment, the patient also creates a hierarchical list of problem behaviors that interfere with their living the life they want to live.
Stage 1:
In this stage, the main goal is to reduce the most severe behaviors that greatly impact a person’s life. These include life-threatening behaviors such as suicide and self-injury, therapy-interfering behaviors such as being late to therapy or not completing homework assignments, and quality-of-life-interfering behaviors such as substance misuse and hurtful relationships. Finally, they want to increase behavioral skills that are done in the skills-group format.
Stage 2:
In this stage, the person focuses on emotional experiencing and attending to the trauma in their life, trauma that has often led to misery and desperation.
Stage 3:
In this stage, residual problems such as boredom, emptiness, grieving, and life goals are addressed.
Stage 4:
In this final stage, the person works on deepening their self-awareness and their sense of incompleteness, becoming more spiritually fulfilled, and recognizing that most of happiness lies within the self.
Surveying DBT Skills
DBT assumes that many of the problems that people experience occur because they don’t have, or can’t effectively use, the skills to manage emotionally charged situations. More specifically, the failure to use effective behavior when it’s needed is often a result of not knowing skillful behavior or, if known, how to use it. Consistent with this idea of skills deficit, the use of DBT skills during standard treatment — in group, individual therapy, and coaching — has been found to lead to a reduction in suicidal behavior, non-suicidal self-injury, and depression, and to improve emotion regulation and relationship problems. In Part 3, we thoroughly review these skills:
Mindfulness:
In part derived from Zen and mystical meditative practices, DBT teaches people the importance of how to be mindful. It involves reflecting on two considerations: “What do I do in order to practice mindfulness?” and “How do I practice these mindfulness skills?”
Interpersonal effectiveness:
DBT teaches more effective ways for people to get what they need and what they want, how to reduce interpersonal conflict, how to repair relationships, and how to say “no” to unreasonable requests. The focus is on helping a person build self-respect, improve their self-advocacy, and recognize their needs as valid.
Distress tolerance:
Whereas many approaches to mental health treatment focus on changing stressful situations, DBT focuses on teaching people skills that allow them to tolerate these situations, which are often fraught with emotional pain or distress. Within the skills, there is also a recognition of the importance of distinguishing between accepting reality as it is and approving of this reality.
Emotion regulation:
Central to many of the problems in which DBT is effective is the finding that people who struggle with regulating their emotions lack the ability to do so effectively. The focus of this skills module is to get people to know what emotion they are experiencing, what the vulnerability factors are to dysregulated emotions, what the functions of emotions are, and then how to deal with the emotions when they are disproportionate to the situation.
Walking through the Mechanics of DBT
As mentioned earlier in this chapter, a comprehensive DBT treatment goes beyond individual therapy and includes group skills training, phone coaching, and a consultation team for the therapists. The group sessions are typically held once per week and run for two-and-a-half hours. In the group, the four skills modules that are mentioned in the preceding section — mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation — are taught. (These are extensively reviewed in Part 3 of this book.)
It typically takes six months to get through all the components of all the modules, and many people who do a course of DBT repeat it. As a result, it takes about a year in total. It can take longer if there are co-occurring disorders such as post-traumatic stress disorder.
In the skills-group session, the first part is dedicated to reviewing the previous week’s assigned homework, while the second part is used for learning, teaching, and practicing new skills. In individual therapy, the skills learned in the group are reviewed within the context of the person’s individual treatment needs and goals. One way to think about this is that the skills groups put the skills into the person, while the individual therapy extracts them in the context of the person’s life.
Treating Specific Conditions with DBT
Most studies on the efficacy of DBT have been completed in people who struggle with borderline personality disorder; however, DBT has been studied in many other conditions (which are more fully reviewed in Part 5). DBT has been shown to have a degree of effectiveness, either on its own or in combination with other behavioral therapies, for conditions such as the following:
Post-traumatic stress disorder (PTSD)
Substance use disorder (SUD)
Binge eating disorder (BED)
It has also been used in diverse populations:
Adolescents (see
Chapter 13
)
Prison populations
People with developmental disabilities
Family members of people with borderline personality disorder
Students who would benefit from a social-emotional learning curriculum in schools
Chapter 2
Understanding Dialectical Behavior Therapy
IN THIS CHAPTER
Examining the biosocial theory behind DBT
Getting into the goals and functions of DBT
Exploring DBT treatment modes
Digging into the dialectical process
Dialectical behavior theory (DBT) was initially developed by Marsha M. Linehan, Ph.D., a psychologist at the University of Washington, to help adult women with a condition known as borderline personality disorder (BPD). BPD is characterized by intense swings in emotions, difficulties with intimate and close relationships, self-destructive behavior, and at times suicidal behavior. For many people with BPD, the possibility of death by suicide makes it one of the most difficult of mental health conditions to treat. In fact, before DBT, BPD was considered a uniquely difficult psychiatric condition to treat; neither medications nor psychotherapy seemed to provide any kind of immediate relief.
However, because people who were suicidal were not “just” suicidal but also had many other problems, having a therapy that dealt with all of a person’s problems was essential to having a comprehensive, supportive, and successful treatment. Further, the treatment needed to be useful to both patient and therapist, because many therapists would often find themselves terrified of treating suicidal patients, and so they also needed support.
Enter DBT. In this chapter, you discover the basics of this therapy, including the biosocial theory, treatment functions and goals, modes of treatment, and the dialectical process.
Beginning with the Biosocial Theory
Dr. Linehan recognized that certain conditions and disorders such as BPD were characterized primarily by emotion dysregulation — in other words, difficulty in regulating (through recognizing and then skillfully either tolerating or effectively dealing with the impact of powerful and at times painful) emotions. She stated that these difficulties emerged from the transaction between an individual’s biological and genetic makeup and specific environmental factors (a concept known as the biosocial theory). She noted that people with conditions like BPD had three prominent characteristics:
They tended to be very emotionally sensitive, which means that they tended to react very quickly and with more intensity than the average person to events that led to emotional experiences.
When emotions flared up, they had difficulty controlling them, and this in turn led to behavior that was dictated by their mood state; as a result, when a person with BPD was in a good mood, they could get almost anything done, and when they were in a bad mood, they had a difficult time meeting the expectations of the moment. This type of behavior based on mood is termed
mood-dependent behavior.
When the person experienced these intense and heightened emotions, it took them longer than the average person to get back down to their emotional baseline.
The following sections discuss dysregulation and environmental factors in more detail.
Types of dysregulation
Over time, people who were emotionally sensitive and who didn’t have the skills to manage difficult situations and relationships in their lives would develop enduring difficulties in regulating five areas of daily experience. The term used by therapists for an inability to regulate is dysregulation, and so people with conditions like BPD had the following five areas of dysregulation, a conceptualization originally described by Dr. Linehan in 1993:
Emotion dysregulation:
Emotion dysregulation
is the inability to flexibly respond to and manage one’s feelings in the context of emotional responses that are highly reactive. Typically, these are brief episodes, lasting a few hours, but they feel overwhelming. Although a person with BPD might have difficulty regulating all emotions, irritability and anger are specified in the
Diagnostic and Statistical Manual of Mental Disorders
(DSM), which is the manual that mental health experts use to classify psychiatric conditions.
Interpersonal dysregulation:Interpersonal dysregulation is characterized by a fear, whether real or imagined, that the person with BPD will be abandoned by those closest to them. In this context, the person with BPD will then become desperate to prevent the abandonment from occurring and will then behave in ways to stop it from happening. These ways will often appear to be extreme to the person on the receiving end of the behavior, and at times can be the reason why that person no longer wants to have anything to do with the person with BPD.
Another hallmark of this is that people with BPD tend to develop intense relationships with others, and these are characterized by extremes of, at times, idealizing the other person and then, at other times, devaluing the other person. These fluctuations can happen very quickly and leave the other person feeling bewildered.
Self-dysregulation.
Self-dysregulation
is characterized by having an unstable sense of self and the experience of feeling empty inside. People with BPD can have a very difficult time defining themselves in terms of who they are as people, what their values are, and what their long-term goals and life direction are. At times they look to others and others’ behavior, and try to copy it in order to fit in, but they often recognize that when they simply behave differently, it does not always feel authentic. Another aspect of self-dysregulation is the experience of emptiness, which is an intense feeling of disconnectedness, aloneness, and feeling misunderstood.
Cognitive dysregulation:
Cognitive dysregulation
is characterized by relatively brief episodes of paranoid thinking, and this is particularly true during periods of stress. This means that when the person with BPD has high stress levels, they can begin to imagine that others are intentionally out to get them, even when there is no evidence that this is true. People with BPD can also experience
dissociation,
which is the feeling or thought that they are not real or that the rest of the world is not real.
Behavioral dysregulation:
Behavioral dysregulation
in people with BPD is characterized by extreme, sometimes impulsive, and at times dangerous behaviors. These behaviors are often used as a way to deal with intense and unbearable emotions, and can include self-injurious behaviors, such as cutting and suicide attempts. Other such behaviors include eating behaviors, such as binge eating, substance use as a way to fit in or self-medicate, dangerous sexual behaviors as a way to feel connected, and dangerous driving or excessive spending as ways to feel a rush of positive emotions.
The invalidating environment
The environmental factor that Dr. Linehan proposed was most significant in the development of BPD in a person who had the emotional makeup in the previous section was what she termed the invalidating environment. The invalidating environment has certain characteristics, as you find out in the following sections.
Intolerance of emotional expression
The invalidating environment is intolerant of another person’s expression of private emotional experiences and, in particular, emotions that aren’t supported by observable events. For instance, if a person believes that they are unlovable and becomes extremely sad because of this, it’s typical for others to tell them that it isn’t true and that their statement that they aren’t lovable isn’t supported by the facts. A person feeling unlovable isn’t something that another person can observe, and so simply telling the person who is struggling with such thoughts that what they are thinking isn’t true is invalidating because it takes away the validity of that person’s emotional experience.
In other words, it may be factually incorrect that that person isn’t loved, and yet the emotion that they experience is real and is not readily dispelled simply by someone saying that they shouldn’t feel it.
Invalidation occurs when you tell another person that it doesn’t make sense that they feel a certain way. Telling a person not to feel the way they feel rarely leads them to change their emotional experience, and it also tells them that the way they feel is out of proportion to whatever event elicited the emotion.
Reinforcement of strong emotions
Another feature of the invalidating environment is that it can reinforce displays of strong emotions. Reinforcement is any consequence that comes after a behavior that increases the likelihood that the behavior will either increase or be maintained at current levels.
Another way to think about a reinforcer is that it’s like a reward. So, if a person is ignored when they are distressed at low levels of emotional expression but attended to when they have big emotions, and if what they want is other people’s attention, then it makes sense that high emotions will show up more frequently.
Shame
Another feature of the invalidating environment is that when a person is told that their displays of emotional upset are unacceptable, unwarranted, or unjustified, they often begin to feel shame for having behaved in the way they did or even for having any emotions at all. The problem with this is that shaming someone doesn’t teach them what to do when they are feeling strong emotions, and as such, they don’t learn what to do the next time strong emotions show up. It also prevents a person from learning how to accurately name and label their emotions.
Imagine that a person could not name and label vegetables and that they were told to go buy vegetables but instead came back with bread and milk and were then ridiculed for not having bought vegetables. Shaming this person wouldn’t teach them what they had to do, and long-term shame can cause significant psychological damage. In such situations, what the person actually learns is to oscillate between going to great lengths to prevent the display of big emotions for fear of being punished and then having big emotional eruptions without knowing how to manage them.
Dismissal of problems and reactions
Finally, the invalidating environment tells emotionally sensitive people that their problems are easy to solve. “Oh, just calm down. That’s what I do,” a parent might tell an emotionally sensitive adolescent. Whereas this may be easy for the parent, it might not be for the child. When people who are emotionally sensitive and, according to the biosocial theory, have a biologically hard-wired temperament or disposition toward being emotionally vulnerable, they have a relatively low threshold for responding to factors in the environment that are emotionally arousing.
It would be like a child having been born with a peanut allergy and being sensitive to peanuts in the environment. Telling the child not to have a reaction to peanuts would ignore what the child’s biology is. Similarly, telling a person with emotional sensitivity not to have the reaction they are having ignores their neurobiology.
When other people ignore, dismiss, or punish emotionally sensitive people’s reaction or oversimplify the ease of coping or solving the problem they are experiencing, over time that person is left without adaptive coping mechanisms. Instead, they turn to quickly executable and often self-destructive ways of coping, including behaviors such as self-harm and drug use.
Focusing on the Functions and Goals of a Comprehensive Treatment
Based on the conceptualization of disorders characterized by difficulties in emotion (see the earlier section “Beginning with the Biosocial Theory”), DBT specifically focuses on helping people regulate their emotions in more adaptive ways. And so, DBT includes many behavioral skills that specifically aim to teach patients how to recognize, understand, label, and regulate their emotions.
A comprehensive treatment is needed to help people who are emotionally sensitive. For any treatment to be comprehensive, it must address five essential functions, and DBT is no different. A comprehensive treatment must accomplish the tasks in the following sections.
Motivating the patient and the therapist
A comprehensive treatment motivates a patient to participate in and complete the treatment, and various strategies are used to keep both the patient and the therapist in the therapy. Motivation comes from understanding the person’s goals while at the same time identifying their relevant strengths and relative weaknesses. The therapist works to ensure that they themselves are clear as to what the patient’s goals are, that they have explained how DBT can help the person attain their goals, and then that they and the patient can collaborate in the process. Motivation goes beyond just the patient. It also targets the therapist’s motivation, particularly when then are finding the work to be frustrating. We review motivational strategies in greater depth in Chapter 19.
Teaching the patient new coping mechanisms
A comprehensive treatment teaches the patient new ways of coping with life’s challenges or enhances a person’s existing capabilities. In DBT, therapists hold the assumption that people who are struggling aren’t doing so out of choice but rather that they lack, or need to improve, several important life skills, including the following:
The ability to regulate emotions
The ability to pay careful and accurate attention to the experience of the present moment
The ability to tolerate difficult moments
The ability to effectively negotiate relationships
The idea is that maladaptive or ineffective behaviors are replaced by healthier, more effective, and longer-lasting ways of managing difficult moments. The teaching of these skills usually takes place in a weekly skills group session, which usually has up to ten patients and two co-leaders. The group generally lasts 90 minutes and has a didactic component where skills are taught, and homework is assigned and is reviewed in the next skills group. We cover skills therapy later in this chapter.
Incorporating new skills into the patient’s daily life
Comprehensive treatment generalizes the new skills and new ways of coping to a patient’s daily life. If the skills learned in therapy sessions don’t apply or transfer to patients’ daily lives, then it would be difficult to say that therapy was successful. This function is accomplished in two ways:
In the skills training group, the therapist provides and then reviews the weekly homework assignments given in the skills group.
The patient is allowed to contact the therapist between sessions so that they can get help directly from the therapist in situations where the patient doesn’t know what to do or how to apply the skills. (Find out more about phone coaching later in this chapter.)
Supporting the therapist
To be effective in the work they do, therapists delivering DBT treatment must stay motivated to work with patients, particularly those patients whose behaviors they find challenging. Many therapists find the work with patients who have BPD and related conditions to be very rewarding, while at the same time, their patients’ intense emotions and at times self-endangering behaviors can lead to therapist burnout and despair.
Therapists who provide DBT are required to sit on a consultation team, which is a group of other DBT therapists who meet on a weekly basis to help each other by using the same techniques that they use with their patients. Therapist burnout is essential to deal with and is applied by using consultation with the therapist, problem-solving, validation, and ongoing training and skill-building, as well as encouragement to persist in applying compassionate care. The typical consultation team meets once per week for one to two hours. We talk about consultation teams in more detail later in this chapter.
Structuring the patient’s environment
Structuring the environment, when necessary, in a way that maximizes the chance of success includes the use of reinforcement of adaptive behavior and not reinforcing maladaptive behavior. Structuring also includes helping patients modify their environment. For example, patients who use drugs might modify their circle of friends. People who use dating apps that have led to abusive relationships may be coached to delete the apps. Patients who struggle by staying up late at night might need to modify their nighttime routine to promote better sleep hygiene.
Patients may need help in finding ways to modify their environments. Typically, the patient is coached as to how to make the modifications, but for younger or less skilled patients, the therapist may need to take a more active role in helping structure the environment. Get the scoop on structuring the environment in Chapter 16.
Checking Out Modes of Treatment
How can the five essential functions in the preceding section be attained? There are four modes of treatment in the standard model of DBT to ensure that the treatment can be comprehensively applied. Not included in these four modes are other modes of treatment, such as medications and services like case management. These other modes can be added to DBT, and often; however, they aren’t core to the treatment.
Skills training
The mode of treatment most frequently implemented in DBT is the skills group. There are various reasons for this. Pragmatically it’s easily implemented and structured. It can meet the needs of many patients because it teaches more than one patient at a time. It has a set curriculum, handouts, and homework, so it appears very much like a typical classroom setting. Further, many mental health settings don’t have enough DBT-trained staff to have every patient be assigned to an individual therapist, and in this context, a therapist working with a co-leader can, at a minimum, introduce a larger number of patients to the treatment. It’s important to note that there is strong evidence that the use of skills training alone is effective in helping patients with many of their mental health symptoms.
In this mode, patients focus on learning new skills in a classroom-like atmosphere. The skills are then enhanced through practice exercises, as well as generalized to other aspects of the patients’ personal lives by the assignment and review of homework. The specific skills that are taught are the four DBT skills modules: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. The modules are typically taught over six weeks, although this can vary, depending on the needs of the patients and how quickly they learn the material. The specific skills are reviewed in depth in Part 3.
In a group meeting, the typical structure is once per week, lasting somewhere between two and two and a half hours. The first hour is devoted to a review of the homework assigned in the previous session, and the second hour is dedicated to the teaching of new skills. Homework is then assigned as the last task of the group.
Note: There are certain circumstances when skills are taught in individual sessions. For instance, a person may have work limitations that don’t allow them to participate at a particular time, or they may have language limitations or learning disorders that don’t allow them to keep up with the pace of teaching in a large group.
Individual therapy
Individual treatment in standard DBT is conducted weekly or biweekly in 60-minute sessions, and it’s focused on understanding, exploring, and targeting the behaviors that a patient wants to change. It does so by keeping the patient motivated to complete the treatment and encouraging them to apply the new skills they have learned in the group. A variety of techniques, which are covered in Part 4, are used by the DBT therapist to address motivation when it has started to wane.
Phone/skills coaching
The skills of DBT are of little value unless they are put to use in the moment that they are needed. When times are calm and emotions are better regulated, it’s easy to see how the skills can be useful, and many patients can explain how the skills would work in their day-to-day life. However, in times of emotional turmoil, the more familiar, often maladaptive, behaviors are the ones that tend to show up first. When the urges to self-harm or use substances show up, the more intense the emotions, the more likely the unskilled person is to use these old forms of dealing with the urges.
Dr. Linehan recognized that life’s most challenging problems tended not to happen when patients were in therapy. They could happen at any time, day or night. She emphasized the importance of intersession coaching to help patients generalize the skills they had learned in the skills training group to their everyday life. The duration of a skills-coaching call is intended to be a brief call of typically no more than 15 minutes to offer patients support and ideas to deal with an in-the-moment situation.
One of the major concerns that new therapists worry about is that spending time out of session on the phone with their patients might reinforce life-threatening behavior. In other words, they worry that if patients feels supported during a call when they are feeling suicidal, it’s possible that they may then express more suicidal thoughts to be able to speak to their therapists more frequently. Therapists are taught how to deal with this eventuality (see Chapter 14).
A therapist consultation team
One of the more difficult aspects of working with suicidal patients is that it’s common for therapists to become discouraged and burned out. Dealing with suicidal people every day can make therapists feel much of the despair that their patients feel. Behavioral change can take time, and many therapists worry about their patients’ safety during episodes of emotional distress. The therapist consultation team is intended to be therapy for the therapists, supporting them in their work with patients who have severe, complex, and often difficult-to-treat disorders.
In the same way that individual therapy helps the patient stay motivated for treatment, the consultation team works to ensure that the therapist remains motivated in order to provide the best treatment possible. Teams typically meet weekly for an hour to an hour and a half, and are composed of individual therapists, family therapists, group leaders, and anyone else providing DBT therapy. It’s such an essential component that a therapist can’t say that they are providing DBT therapy if they aren’t on a consultation team. Chapter 17 covers therapist consultation teams in more detail.
Incorporating Dialectics
The fundamental principle underlying the practice of DBT is the recognition of and emphasis on the dialectical process. The dialectical philosophy at the core of DBT is that seemingly opposing experiences such as thoughts, emotions, or behaviors can coexist, and both make sense. In other words, two ideas that are seemingly in complete opposition to each other can both be true at the same time. This requires that a therapist and a patient be able to look at a situation from multiple perspectives and find a way to synthesize the seemingly opposite ideas.
Within this framework, reality consists of opposing forces that are in tension, not dissimilar from a game of tug-of-war. As it pertains to therapy, in many cases the push to apply change-oriented treatment strategies often creates a resistance to the recommendations. The therapist pulls in one direction and the patient in another. This is because the prospect of facing the emotional turmoil and suffering that many people with conditions like BPD experience during therapy feels more painful than they are willing to bear. Dialectical philosophy also recognizes that opposing forces are incomplete on their own; you can’t have a tug-of-war with only one team.
Practitioners noted that it was by moving into a collaborative and accepting stance, rather than one solely focused on trying to get their patients to change, that the possibility of change occurred. And so, when the therapist balances and synthesizes both acceptance and change-focused strategies in a compassionate therapy, the patient experiences the freedom they need to heal. In many cases, prior to DBT, patients experienced the opposite. They either noted locking horns with their therapists, who insisted that the patients had to change, or they experienced passive, though caring, therapists who simply listened and didn’t offer ideas that could help. In some cases, individual therapists would swing between the two extremes, another style that was unhelpful to patients who themselves would tend to swing between extremes.
