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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
An effective skills-building resource for achieving real change with dialectical behavior therapy
Dialectical behavior therapy (DBT) is the type of talk therapy with the most evidence-base for people who experience painful swings in emotions and volatile relationships. It is most commonly applied in the treatment borderline personality disorder who also experience suicidal thinking and behaviors and in recent years, therapists use it for other mental health conditions as well.
With DBT, you can learn to regulate your emotions, tolerate distressing situations, improve your relationships, and apply mindfulness in your daily life. DBT Workbook For Dummies puts healing in your hands, giving you step-by-step exercises for learning these concepts and putting them to work. Great for patients, family members, and clinicians, this book is an essential resource for understanding emotions and behavior and then learning how to handle uncertainty when emotions and relationships are in flux. These clear and practical explanations and activities make it easy to move toward a new you.
- Learn the basic concepts of dialectical behavior therapy and apply them in your life
- Become more resilient by using coping skills that will help you achieve your goals
- Work through hands-on exercises that will help you navigate relationships, increase self-awareness, and overcome the impact of strong and painful emotions
- Manage mental health issues arising from intense emotions, poor self-esteem, and stressful situations
Great on its own or paired with DBT For Dummies, this book will help patients, their family members, and DBT therapists in the search for concrete actions that promote thriving in the long term.
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Seitenzahl: 439
Veröffentlichungsjahr: 2024
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DBT Workbook For Dummies®
To view this book's Cheat Sheet, simply go to www.dummies.com and search for “DBT Workbook For Dummies Cheat Sheet” in the Search box.
Table of Contents
Cover
Title Page
Copyright
Foreword
Introduction
About This Book
Foolish Assumptions
Icons Used in This Book
Beyond the Book
Where to Go from Here
Part 1: Getting Started with DIY DBT
Chapter 1: Beginning Your DBT Journey
The Origins of DBT
Deconstructing Dialectics
Modes of Therapy and Their Functions
Components of DBT
Chapter 2: Digging into the Benefits of DBT
Unmanageable Emotions
Unrestrained Behaviors
Disrupted Relationships
Confused Cognitions
An Unstable Self
The Dysregulation Cycle
Part 2: Preparing Yourself for Skillful Living
Chapter 3: Setting a Commitment to DBT
Pinpointing Your Problems
Does Every Problem Need a Solution?
Identifying Your Goals
Making a Commitment to Change
Generating Hope/Cheerleading
Chapter 4: Being Intentional
Moving Beyond Your First Reaction
Reacting with Intention
Chapter 5: The Principles of Behavior
Taking the First Step
Understanding the Function of Behaviors
Recognizing Reinforcers
Understanding Shaping
Pivoting on Punishment
Part 3: Practicing DBT
Chapter 6: Mindfulness
What Is Mindfulness and What Are Its Benefits?
Understanding Your Own Mind
Practicing Mindfulness
Setting a Routine and Building Your Practice
Chapter 7: Emotion Regulation
What Is Emotion Regulation and What Are the Benefits?
Understanding and Identifying Your Emotions
Naming Your Emotions and Decreasing Emotional Suffering
Chapter 8: Interpersonal Effectiveness
Understanding What Gets in the Way of Your Relationships
Mastering DEAR MAN Skills
The Art of Validation
Communicating with GIVE Skills
Staying True to Yourself with FAST Skills
Combining GIVE and FAST Skills
Managing Interpersonal Anger with THINK Skills
Chapter 9: Distress Tolerance
What Is Distress Tolerance?
Employing Crisis Survival Skills
Accepting Reality
Putting It All Together: Your Own Crisis Kit
Chapter 10: Walking the Middle Path
What Is the Middle Path?
Middle Path Dialectical Dilemmas
Chapter 11: Digging into Dialectics
Recognizing the Dialectical Dilemmas
Working Through Your Dialectical Dilemmas
Embracing the Paradox
Part 4: It Doesn’t End Here: Living a DBT Lifestyle
Chapter 12: Living a Life without Mood-Dependent Behaviors
Using DBT Skills to Regulate Your Emotions
Wisely Setting Goals
Breaking Down the Steps
Maintaining Motivation
Observing Obstacles
Eliminating Emotional Decision Making
Chapter 13: Focusing on Future Self
Identifying the Person You Want to Be
Benefits of Connecting with Your Future Self
Recognizing Present-Self Behaviors
Aligning Your Present and Future Self
Part 5: The Part of Tens
Chapter 14: Ten Tips for a Skillful Life
Periodically Review Your Short- and Long-Term Goals
Never Stop Learning
Practice Wholistic Health
Limit Drugs and Alcohol
Limit News and Social Media
Be Accountable to Others
Accumulate Positives
Build Mastery
Use the Coping Ahead Skill
Practice Flexibility
Chapter 15: Ten Ways to Overcome Obstacles
Anticipate Obstacles When You Can
Validate the Emotions that Show Up
Remember to Breathe
Keep Your Goal in Mind
Practice Effectiveness
Understand the Problem
Engage in Problem Solving
Ask for Help If You Need It
Pivot If You Need To
Use Encouragement to Stay in the Process
Chapter 16: Ten Ways to Self-Validate
The Benefits of Self-Validation
Ten Steps to Validation
Index
About the Authors
Advertisement Page
Connect with Dummies
End User License Agreement
List of Illustrations
Chapter 3
FIGURE 3-1: The Goal/No Goal dialectic.
Chapter 10
FIGURE 10-1: Walking the Middle Path example.
Guide
Cover
Table of Contents
Title Page
Copyright
Foreword
Begin Reading
Index
About the Authors
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DBT Workbook For Dummies®
Published by: John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030-5774, www.wiley.com
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Foreword
Dialectical Behavioral Therapy (DBT) has changed my life. Dr. Gillian Galen and Dr. Blaise Aguirre are on the forefront of a movement started by Dr. Marsha Linehan, one that had a far greater impact on my life than I would have ever imagined. What I have gained from DBT is almost impossible to condense into this short foreword, but it's worth trying.
Despite being blessed throughout my life in so many ways, chapters of my life have been more difficult than they needed to be because of avoidance, emotional dysregulation, and the inability to move past my own failings. This has led to fractured relationships, mental illness, and suffering for myself and my loved ones. I turned to DBT as the latest of several failed efforts to “fix” my relationships and myself. That journey, which proved to be more life-changing than I could have ever imagined, led me to the doorsteps of Drs. Galen and Aguirre.
As the cohost of “Morning Joe” and the creator of the women’s empowerment platform “KNOW YOUR VALUE,” I've had the opportunity to meet world leaders, as well as titans in all areas of business, arts, politics, and foreign policy. I have met people on the front lines of conflict resolution, peacemaking, diplomacy, geo-strategic negotiation, and relations around the world. In every aspect of conflict, discrimination, inequality, and even war, I am certain that DBT could dramatically improve and repair turbulence and upheaval. From peace in the Middle East, to managing NATO and Russian aggression, to the dangerous political divisions within the United States, if DBT were the norm, the question would not be how to solve these struggles, but rather whether these struggles even existed in the first place.
Division, anger, hatred, violence, and intolerance all come from a lack of acceptance, avoidance, and an inability to regulate emotions. DBT addresses all of these struggles. That is why this workbook can effectively be utilized by schools, colleges, businesses, and even governments around the world.
DBT works—in fact, the skills are so effective that one can move from a time in their life where they are diagnosed as “ill” and miserably depressed, to someone who experiences joy and a sense of steadiness and confidence. Fulfilled and validated. Through “KNOW YOUR VALUE,” I teach women how to negotiate for raises and how to get “value back” in every relationship. Every tenant of DBT has made my message more effective and easier to teach. Learning skills like validation, radical acceptance, mindfulness, and, most importantly for me, emotion regulation—that’s the value of DBT. Make no mistake: DBT takes consistent work. At the same time, this workbook makes it doable. DBT Workbook for Dummies walks you through the skills. With repetition, these skills can become second nature, and your life will start to get better and better every day. For me, the sun came up on all my relationships, and most importantly with the people I love—my family. These skills can save your relationships too, and the world.
—Mika Brzezinski, American talk show host, political commentator, and author
Introduction
If you recall from our first book, DBT for Dummies, dialectical behavior therapy (DBT) is a powerful evidence-based treatment developed by Dr. Marsha M. Linehan to help people navigate lives filled with emotional chaos and turbulent relationships. It combines elements of cognitive behavioral therapy (CBT) and change techniques with mindfulness and acceptance practices. By combining mind and body, DBT offers a more holistic approach to addressing mental health suffering.
This workbook was developed as a companion to DBT for Dummies and is designed to be a personal guide as you work toward a life worth living. Your journey will include practices that will reduce your emotional reactivity, increase mindful awareness, help you build more enduring and fulfilling relationships, and create an improved ability to tolerate difficult moments. If you read DBT for Dummies, you will be familiar with the therapy, and this book will help you deepen your understanding and practice, but even if you are new to the concepts of DBT, this workbook is here to support you every step of the way.
As you embark on this journey, remember that change is a process, and each small step you take brings you closer to your goals. This workbook is not just about completing exercises; it is about integrating these skills into your daily life, fostering a deeper sense of self-awareness and resilience. The book provides tips, reminders, and cross references as a way to interconnect the various skills into a toolbox of abilities.
About This Book
Within these pages, you will find a series of exercises, activities, and reflections carefully crafted to prompt the practice, strengthening, and generalization of the core DBT skills. From learning effective ways to manage intense emotions to improving effectiveness in relationships, each chapter is designed to build on the last, creating a solid foundation for your personal growth.
This book is meant to be written in; additional worksheets and practices are available online. Because these skills are meant to be practiced and integrated into your life, consider identifying worksheets that you may want to have on hand to help you practice certain skills throughout the day or week. One of the assumptions of DBT skills training is that DBT skills should be learned and generalized in all important contexts of your life. Our hope is that this workbook will be your guide.
You can use this workbook on your own, in individual therapy, and in your DBT skills group. Know that you are not alone; because of the power of DBT, millions of people worldwide are using the approach to create meaningful, fulfilling lives — ones with less suffering and more empowerment and self-agency. We hope this guide will be as helpful to them as it is to you.
Set aside some time for yourself, you deserve it! Take a deep breath, stretch your body, and let us join you on your journey to a more skillful and fulfilled you, with this workbook as your roadmap. You’ve got this!
Foolish Assumptions
As DBT therapists, we make few assumptions about you! You are reading this book to continue your quest to learn DBT and integrate these skills into your life. You may have some basic understanding of DBT, or this may be the first step to a more skillful life. We will guide you on this journey, and you must make the commitment to practice the skills. If you practice these skills, the way you live and experience your life will begin to change.
We recognize that no book is a substitute for expert therapy, and we assume that anyone who needs help will seek it out. We also assume that readers who are suffering may find these skills challenging and find change overwhelming, and we remain committed to acting as your guide and a place to come back to at any time. Finally, as all DBT therapists do, we assume that at any given moment, we are all doing the best we can, and we can always do better, try harder, and be more motivated to change!
Icons Used in This Book
Throughout this book, icons in the margins alert you to important types of information:
This icon marks particularly noteworthy information that you might record or write down so you can refer to it later.
This icon tells you it’s time to roll up your sleeves and get to work! It denotes a worksheet, form, or exercise for you to fill out.
This icon points to specific examples that show you the way through worksheets or exercises. Examples are fictional composites that represent accurate struggles, but they’re not real people.
This icon appears when you need to take care; you may need professional help or should be on the lookout for possible trouble.
This icon alerts you to especially useful insights and explanations.
Beyond the Book
Throughout the book there are worksheets that you may want to complete more than once. Go to www.dummies.com/go/dbtworkbookfd to download blank versions that you can print and use.
In addition, there’s a cheat sheet with tips and information about anxiety and depression. To access this online cheat sheet, go to www.dummies.com and then type “Dialectical Behavior Therapy For Dummies Cheat Sheet” in the search box.
Where to Go from Here
DBT Workbook For Dummies can help you deal with emotional chaos and turbulent relationships in your life. It’s pragmatic, concrete, and goes straight to the point. As such, this workbook doesn’t devote a lot of text to lengthy explanations or embellishments of basic concepts, so you may want to find out more about specific types of therapy and alternative treatments elsewhere. For that purpose, consider reading one or both of the companion books: DBT For Dummies (Wiley), Depression For Dummies (Wiley), and Anxiety For Dummies (Wiley).
Part 1
Getting Started with DIY DBT
IN THIS PART …
Learning about DBT and its elements and what your journey will look like
Exploring the benefits of DBT
Chapter 1
Beginning Your DBT Journey
IN THIS CHAPTER
Overviewing the origins of DBT
Diving into dialectics
Focusing on the function of behavior
For people all over the world, these past several years of unrest, divisiveness, fear, and uncertainty have increased stress significantly. Stress often precedes the emergence of emotional disorders, especially anxiety and depression. In the United States, recent surveys suggest that about 40 percent of the adult population suffers from notable symptoms of anxiety or depression. The rates of anxiety and depression among adolescents have also risen dramatically due to disruptions in their lives during these tumultuous times.
This workbook is designed to help with troubling emotions. It isn’t meant to be a comprehensive review of emotional disorders. Many people choose to use this book along with professional counseling or therapy, and some use it on their own. If you want more information and an in-depth discussion of DBT, take a look at DBT For Dummies. If you want more about anxiety or depression, take a look at the latest editions of Anxiety For Dummies or Depression For Dummies.
If your symptoms are numerous and severe or your life seems out of control, you should consult your primary care provider or a mental health professional. These worksheets aren’t meant to replace trained mental health professionals — they’re the only people who can really diagnose your problem.
The Origins of DBT
Dialectical Behavior Theory (DBT) was initially developed by Dr. Marsha Linehan PhD, a psychologist at the University of Washington. Her motivation was to help adult women with a condition known as Borderline Personality Disorder (BPD). BPD is characterized by a person having intense and painful mood swings, difficulties in intimate and close relationships, negative ways of thinking about oneself, self-destructive behavior, and suicidal behavior. For many people with BPD, this confluence of symptoms paired with the reality of the risk of suicide makes it one of the most difficult mental health conditions to treat. In fact, before DBT, BPD was considered a uniquely difficult psychiatric condition to treat and contributed to stigma about BPD.
What Dr. Linehan realized was that certain conditions and disorders such as borderline personality disorder (BPD) were characterized primarily by emotion dysregulation. In other words, some people had difficulty controlling their emotions and emotional expressions.
She hypothesized that these difficulties arose from the transaction between an individual’s biological and genetic makeup and specific environmental factors, and she called her theory the biosocial theory. She noted that people with conditions like BPD had three prominent characteristics:
Sensitivity:
They tended to be emotionally sensitive, which means that they experienced emotions more quickly and with more intensity than the average person in response to events that led to emotional expression.
Reactivity:
Next, she noted that when emotions showed up, emotionally sensitive people had difficulty controlling their emotions and that this led to behavior dictated by their mood state. When emotionally sensitive people were 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.
Slow return to baseline:
And finally, she noted that when the emotionally sensitive person experienced these intense and heightened emotions, it took them longer than the average person to get back down to their emotional baseline.
Don’t worry if the worksheets in this chapter reveal that you have a few symptoms of emotional dysregulation. Almost everyone has struggles; that’s human. However, you should be concerned when these symptoms significantly interfere with your life. As mentioned in the Introduction, you can find blank versions of these worksheets online (at www.dummies.com/go/dbtworkbookfd) that you can print and use.
Take some time to go through Worksheet 1-1 and identify areas in which you have experienced intense emotional reactions.
Worksheet 1-1 Emotional Reactivity
Do you recognize these characteristics in yourself? If you do, what are some examples of times when you have experienced this type of emotional response? In other words, give an example when you felt emotions quickly and more intensely, when you stayed emotionally upset for a long period of time, or when your emotional state changed. What did you do in those situations?
Linehan recognized that there were five types of dysregulations that impacted people who had problems with managing their emotions. Dysregulation is a term used by therapists, and it means an inability to regulate or to control. Linehan noted that for emotionally sensitive people — and in particular those who did not have the skills to manage difficult situations and relationships in their lives — difficulties regulating the following five areas of daily experience persisted. These types of dysregulation are not one-time events, but rather are patterns of behavior that persist over time.
The five areas of dysregulation and areas for which DBT has been found to be most useful, are as follows:
Emotion dysregulation:
Emotion dysregulation is the inability to flexibly respond to and manage emotions in the context of difficult circumstances. Instead of a measured response, for people who struggle with emotion regulation, their responses are highly reactive. Typically, these moments of reactivity are brief, lasting at most a few hours. These emotions nevertheless feel overwhelming and out of control.
Interpersonal dysregulation: Interpersonal dysregulation is the experience of being ineffective in close relationships. This can happen because of fear, whether the fear is real or imagined, that the person 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 behave in ways to prevent the abandonment from happening. These desperate ways will often appear to be extreme to others.
Another hallmark of interpersonal dysregulation is that people with BPD tend to develop intense relationships with others, characterized by extremes. Sometimes they idealize the other person and other times they devalue the other person. These fluctuations can happen very quickly and leave the other person feeling bewildered.
Sense-of-self dysregulation:
Sense-of-self-dysregulation is the experience of having very little consistency in one’s identity. 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 is. At times, they look to others and try to copy their behavior in order to fit in, but in many cases, this doesn’t 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 or misperceiving reality, 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. Then, at times when emotions are powerful and painful, and this is especially true if the person has experienced significant trauma, people with BPD can have episodes of
dissociation
, which is the feeling or thought that they are not real or that the rest of the world is not real. The physical seems to disconnect from the emotional self.
Behavioral dysregulation:
Behavioral dysregulation is the manifestation of 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 self-medicate, dangerous sexual behaviors as a way to feel connected, and dangerous driving or excessive spending as a way to feel a rush of positive emotions. People often report that they feel out of control in these instances; like they don’t have the ability to refrain from engaging in the behavior.
These five areas of dysregulation can often intertwine in very painful ways. For instance, emotional dysregulation can lead to cognitive, behavioral, and interpersonal dysregulation. Interpersonal dysregulation can lead to emotional dysregulation, and so on. For many, feeling like they don’t have a stable sense of who they are can lead to feeling out of control. Use Worksheet 1-2 to reflect on the areas of dysregulation that you've experienced personally.
Worksheet 1-2 Dysregulation
My experience of:
Emotional dysregulation
What are two or three examples of this?What behaviors typically follow emotional dysregulation?When does emotional dysregulation tend to occur (time of day, day of week, location)?What tends to prompt emotional dysregulation (thoughts, other emotions, interactions with certain people?)Interpersonal dysregulation
What are two or three examples of this?Are there particular people who tend to cause interpersonal dysregulation?What behaviors typically follow interpersonal dysregulation (fights, yelling, avoidance)?What tends to prompt interpersonal dysregulation (abandonment fears, disappointment, feeling judged)?Sense-of-self dysregulation
What are two or three examples of this?What does sense-of-self dysregulation look like for you (constantly changing values, defining self by what others do, constantly changing aspirations and goals)?When does sense-of-self dysregulation tend to show up (applying for jobs, deciding on fashion, being asked to give an opinion on a politically charged topic)?Cognitive dysregulation
What are two or three examples of this (black and white thinking, certainty unsupported by facts, paranoia, dissociation)?When does cognitive dysregulation tend to occur (under stress, with certain people, by painful memories)?Behavioral dysregulation
What are two or three examples of this?In what way are the behaviors potentially dangerous?When does behavioral dysregulation tend to occur (time of day, day of week, location)?What tends to prompt behavioral dysregulation (thoughts, interactions with certain people?)Deconstructing Dialectics
The fundamental principle underlying the practice of DBT is the recognition and emphasis on a dialectical way of thinking. Dialectics is at the core of DBT and is the acknowledgment that seemingly opposing experiences — including thoughts, emotions, or behaviors — can coexist. Not only can they coexist, but even though they may seem opposite in perspective, they can both contain truths at their core.
Here is a simple example that highlights this. Imagine a game of basketball. One person roots for one team, and another person roots for the other team. At the end of the game, one person is happy and the other is sad. Both of those experiences are true, coexist, and make sense.
This applies to mental health as well. Within the DBT framework, reality consists of opposing forces and experiences in tension, not dissimilar from the two fans of opposing teams in the basketball game. When it comes to therapy, therapists often push their patients to change. However, because it can be difficult, the patient does not easily meet the idea of change. The therapist and the patient often have a common goal, and that is for the patient to be happier and more effective in their life, but one may be pulling and the other may be pushing. It may even feel like a tug-o-war when they seem to be pulling in opposite directions. A practical example of this is, for instance, a therapist pushing a socially anxious client to interact with a co-worker, and yet the client resists because their anxiety causes fear of interacting with others, which they resist out of fear.
Both the experience of wanting to change and of being scared of change — or preferring to stay with the life you know — can coexist, are true experiences, and are understandable from both the therapist’s and the patient’s points of view. It makes sense that the therapist wants the patient to change and that the patient is either resistant or afraid of change. For people with conditions like BPD, the prospect of facing the emotional turmoil and suffering that they often feel during therapy feels more painful than they are willing to bear.
DBT therapists have realized 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. 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, they have experienced the opposite. In the previous example, the DBT therapist with the socially anxious client would acknowledge the difficulty and fear and balance it with problem-solving to determine how to take steps toward the shared goal. They have either noted locking horns with their therapists who insisted that the patient had to change, or they experienced a passive though caring therapist, who simply listened and did not offer ideas that could help. Use Worksheet 1-3 to reflect on times when you've been caught in dialectical thinking.
Worksheet 1-3 Dialectical Thinking
Have you ever locked horns or had moments in therapy when your therapist wanted you to change your behavior and you did not want to do what they asked?
Describe the situation:
What did your therapist want you to do? Can you make sense of why your therapist wanted you to do whatever they were asking?
Why did you not want to do it or find it difficult? How would you explain your struggle to make the change your therapist was asking to someone else? Does it make sense to you that it was difficult?
Can you see how each of your perspectives make sense and are true in the moment, even though the perspectives are opposite, and you may disagree with each other? If you can, you are understanding the core of dialectics.
In DBT, the therapist lets go of the need to be right and is open to the idea that there are other possibilities in the moment. Finally, in DBT, there is an emphasis on moving away from a rigid style of therapy and there is often a lot of movement, speed, and flow within a therapy session. This is achieved by the therapist using various strategies to increase or decrease the intensity, seriousness, lightness, or energy of the therapeutic interaction, and then assessing what works best for any one particular patient, rather than assuming that a single style works equally well for all patients.
The following sections delve more deeply into the dialectical process.
Searching for multiple truths in any situation
The core dialectic in DBT is that acceptance and change coexist. Here is an example. Imagine that you are stuck in very heavy traffic. You can’t get out of the car, there are no nearby exits, and your mobile app tells you that you are at least an hour away from a meeting that you should have been at 30 minutes ago. What can you do? For some people, there could be rage, for others resignation, for others, an attempt to solve the problem a different way, for instance calling in to the meeting.
There are a few realities in the moment:
You are stuck in traffic.
There are no nearby exits to get out of the traffic.
You are 30 minutes late for a meeting.
You have a response to this situation.
Of course, more than anything, you would like the situation to change! You have two main options:
To accept the reality of the situation in the moment.
To reject the reality, or parts of the reality, of the situation in the moment.
So, if you decide that you are going to fully accept that this is the situation you are in, where does change come into the picture? A traffic jam can be aggravating, and especially if you are late for a meeting, it can lead to persistent suffering.
Another way to consider it is to say, “I cannot make the traffic be anything other than what it is, but I can change my reaction. I can learn to relax when I am in intolerable situations.”
Imagine that you have an identical twin traveling in the car next to you, and you are both in the same traffic. Imagine that you were not accepting reality and fighting it all the way, feeling that it is unfair the traffic was so bad. What would your state of mind be? On the other hand, if your twin accepted that this is the reality in this moment and decides not to fight reality, but instead recognizes that the one thing that they can control is their state of mind and their reaction to the stressful situation, they would be in a far more relaxed state of mind. That represents change. Change and acceptance are occurring at the same moment. Research shows is that the more emotionally regulated a person is, the more capable they are of solving problems, and that the more dysregulated a person is, the fewer options come to mind.
From a philosophical perspective, dialectics say that we have the thesis on one side, meaning one concept (the traffic is unbearable) and an antithesis on the other side, meaning an opposite concept (you can change your reaction to the traffic). Then comes what Dr. Linehan termed the dialectical synthesis, which is the integration of the two perspectives and that is, “I can be in a situation that I don’t like, and yet accept it. By doing so, I can make the changes necessary to be more effective. Difficult moments become opportunities for me to learn to be more capable and skillful.”
Worksheets 1-4 and 1-5 help you pinpoint coexisting opposites currently causing stress in your life and think of them in different ways.
Worksheet 1-4 Coping with Coexisting Opposites
Think of a situation that you might be struggling with, such as a difficult relationship, struggles at work, or the urge to do behaviors that you know aren’t healthy in the long run.
For example, if it is a relationship that you are struggling with, write down some facts about the relationship (the positives and negatives) and then reflect on what makes it difficult. Can a person who is supportive still have qualities that are unhelpful, and can a person who is less supportive still have qualities that are kind? Write down all the opposites.
Use the word AND rather than BUT. For instance, say your friend tends to be late for get-togethers. Saying “My friend is emotionally available AND at the same time unreliable when we make plans” says that both are true. Saying “My friend is emotionally available BUT unreliable when we make plans,” tends to diminish the value of the friendship.
Worksheet 1-5 Depolarizing Experiences Using AND
What is the issue that tends to pull you into extremes?
Write down all the elements of the situation as clearly as you can, adding as many specifics as you can.
What are some of the benefits of the situation and what are some negatives? You can validate that the positives are positive and that the drawbacks are negative.
Next, is there a way that you can integrate the positives and negatives, using the word AND, to come up with a new way of seeing the situation?
Here are some examples:
I don’t like the way my sister teases me AND she is always there for me.
My coach is pushing me so hard that I am exhausted and want to quit AND her coaching is making me a better player.
It’s painful that I didn’t get invited to the party AND I am happy that I have the time to read my new book.
The point is that by simply focusing on the negative, you get stuck in suffering. There is always another side to a situation. Practicing thinking in this way can help you suffer less and see things more clearly.
The bottom line: In DBT, dialectics is the practice of looking at the synthesis of thesis and antithesis. In doing so, the practice:
Acknowledges that change is the only constant in the universe, and that the process is continuous.
Acknowledges that all things are made of opposing forces.
Focuses on bringing together the most valuable parts of the opposing forces to form a new meaning, understanding, or solution in a given situation.
DBT assumptions
People are usually told to avoid making assumptions. Yet, every therapy operates with a certain set of basic assumptions. For instance, psychoanalytic therapy assumes that there is a dynamic unconscious, which is made up of the thoughts and feelings that are actively kept out of consciousness by the action of what Freud termed defenses. And like other therapies, DBT is no different. It operates with a certain set of clearly articulated assumptions. Having assumptions about patients and the treatment allows providers to agree and work together from a common place.
In DBT, therapists agree that they will see their patients and others while holding these assumptions in their mind. Assumptions about patients (and all of us):
People (all of us) are doing the best that they (and we) can.
People want to improve.
People need to do better, try harder, and be more motivated to change.
People must learn new behaviors, both in therapy and in the context of their day-to-day life.
People cannot fail in DBT.
People may not have caused all of their problems and they have to solve them anyway.
The lives of people who are suicidal are unbearable as they are currently being lived.
Many people, including therapists and loved ones, at first find it confusing to hold these assumptions in mind. When they see a patient or loved one behaving in self-destructive ways, they understandably ask, “How can I accept that my patient or loved one is doing the best they can?” The idea in DBT is that a person is doing the best they can, given their circumstances in that moment. Additionally, these assumptions help providers (and patients and others) start from a non-blaming and compassionate foundation. Use Worksheet 1-6 to challenge your own assumptions and learn to be kind and accepting of your efforts.
Worksheet 1-6 Assumptions
Think about this for yourself. Do you behave in the same way when you are hungry, tired, emotional, under the influence of substances, or sick? Can you accept that the best you can do when you are not feeling at your best is different from the best you can do when you are feeling beaten down?
Review the assumptions and see how they apply to you. Think about your vulnerability factors, your past treatments (if you have been in treatment before), and so on, and write down your reflections.
Assumptions about treatment
In the same way that DBT has assumptions about patients, it also has certain assumptions about the treatment itself. All adherent DBT therapists review these assumptions and use them as guideposts to keep on track.
The most caring thing a therapist can do is help people change in ways that bring them closer to their own ultimate goals.
Clarity, precision, and compassion are of the utmost importance.
The treatment relationship is a real relationship between equals.
Principles of behavior are universal, affecting therapists no less than patients.
Treatment providers need support.
Treatment providers can fail, and they can fail in helping their patient even if they provide the best therapy.
Therapists recognize that they are human beings working with other human beings and that the influences that impact their patients also impacts them. They get sad, try their best, fail at times, and so on. And so, although therapists may have a greater ability to regulate their experience, they are just as human as you are!
DBT principles and protocols
Dialectical behavior therapy is based on certain principles and relies on certain protocols in its application. From a scientific perspective, the term principle means an idea or set of ideas based on scientific rules and laws that are generally accepted by scientists. At the heart of DBT philosophy sit the following principles:
All things are interconnected:
From a DBT perspective, this assumes that a system must be analyzed as a whole and that all people are intimately related to and influenced by all the experiences and interactions that happen between them.
Change is constant and inevitable:
From a DBT perspective, this implies that each of us and the environment are undergoing continuous transition. Because of this, DBT doesn’t focus on maintaining a stable, consistent environment, but rather aims to help a person become more skillful in dealing with the inevitable change.
Opposites can be integrated to get closer to the truth, also known at the
principle of polarity
:
This builds on the idea that not only is reality not static, but that it is made up of internal opposing forces. From a DBT perspective, this also means that within dysfunctions, there is also function, that within destruction, there is also birth, and that within chaos and distortion, there is accuracy.
What is interesting about these principles is that they are true when applied to DBT, and they also happen to be true in the context of physics and chemistry. At a practical and application level, the key principles in DBT are the principles of:
Dialectics:
As explained earlier in this chapter, this is the idea that multiple and even opposing truths exist in any context.
Behaviorism:
The idea that all behaviors are learned through interaction with the environment, and that behavior can be changed through the application of behavioral responses such as reinforcement, shaping, and punishment.
Chapter 5
covers this principle fully.
The biosocial theory: The idea that emotional vulnerability and chronic environmental invalidation lead to dysfunction. DBT theorizes that problematic behaviors, emotions, thoughts, and relationships are caused by the interaction between a person’s biological makeup and an invalidating environment. This theory is known as the biosocial theory or the biosocial theory of emotional development.
According to this theory, the interaction between your biology and your social environment leads to the development of your emotions and the behaviors that ensue. On the biological side, which is a product of genes and brain development, some people are more emotionally sensitive. The environmental element that most impacts the ability to regulate emotions is that of the pervasively invalidating environment. Invalidation is the experience of when private emotional experiences are ignored or punished or when the solution to dealing with painful emotions is oversimplified. This interaction over time can help explain why some people tend to struggle with significant and pervasive emotion dysregulation. This dysregulation can have a variety of serious consequences that include behavioral problems, out-of-control emotions, relationship issues, confusion about the self, and so on. People who benefit most from DBT often feel very validated by and relate to having the biosocial theory explained to them.
As an example, say you are an emotionally sensitive person (biology), and your private experience of a situation leads to a strong emotion — you are not invited to a party and you react by being extremely angry and sad at being left out. Let’s then say that people in your environment tell you that you’re making a big deal of the situation, or they say you should just call another friend, or tell you you shouldn’t feel that way — these are all examples of being invalidated.
Interactions where you experience strong emotions that are invalidated over time are problematic because not only are these interactions emotionally painful, but further, they don’t teach you how to manage the emotional experiences. Invalidation also increases disconnection in the relationship (not feeling understood), which can then increase painful emotions. Use Worksheet 1-7 to identify your own such experiences and emotions.
Worksheet 1-7 Validation and Invalidation
Write about a situation that triggered an intense and painful emotional response.
Next, write down the responses of other people who you felt were invalidating your feelings, meaning they said you were making a big deal of the situation, that you should just get over it, and so on. What were their responses, and how did you feel when they responded that way?
Did anyone respond in a validating way, acknowledging who you are and that how you felt was valid and understandable? What were these responses and how did they make you feel? (Chapter 8 goes much more into validation.)
Hopefully, DBT in theory now makes sense, but what does it look like in practice? The next section covers that topic.
Modes of Therapy and Their Functions
In order to deliver DBT, Linehan identified certain modes or elements of the necessary treatment for it to be effective. These modes have specific functions that patients need in order to succeed.
She proposed that for DBT to be effective, the following criteria needs to be met. As you review these, see if they make sense and if they apply to you.
Therapy must tap into a person’s existing capabilities
The first criterion is the idea that therapy must enhance a person’s existing capabilities. This has two components:
Any approach to therapy should recognize that all people have certain capabilities, ones that are effective and working in their life.
Many people who come for treatment don’t believe that this is the case, feeling that they are good at nothing. This is often because the invalidating environment has led them to believe that their abilities and aspirations are of little value.
Patients have to learn new and more adaptive skills in order to deal with life’s challenges.
Use Worksheet 1-8 to identify your own capabilities, as well as skills that you lack or need to work on.
Worksheet 1-8 Capabilities
What are some of your existing abilities, ones that you are proud of, that make you feel competent, such as love of animals, compassion, artistic ability, and so on? Write them down.
Next, what are skills that you don’t have that you need to learn, such as controlling your emotions, reducing the volatility in relationships, and so on? Write them down.
Therapy must encourage a person’s motivation to change
The second criterion is that therapy should enhance and maintain the person’s motivation to change. Many times, people feel that they want to change and may even feel motivated to change, but then the effort seems to be too much and they give up.
A person’s new capabilities must be relevant to all environments
The third criterion is that any therapy should ensure that a person’s new capabilities are generalized to all relevant environments. What this means is that it is one thing to be a perfect and compliant patient in the therapist’s office, but quite another to be skillful in your life. Is your therapy teaching you what to do in the relevant contexts in your life?
Therapy should enhance the therapist’s motivation to treat people
The fourth criterion is that any therapy or approach should enhance the therapist’s motivation to treat people who are struggling as well as enhance the therapist’s capabilities through education and DBT practice. When therapists find that a patient has a complex set of symptoms, they can tend to feel bewildered and not know what to do. DBT therapy requires that DBT therapists be on a consultation team so that they can get help for their struggles, or as Linehan put it: “It is therapy for the therapists.”
Therapy should structure the environment so that treatment can happen
The final criterion is that any therapy should structure the environment so that treatment can take place. In other words, are the conditions in place for therapy to be a viable option? What are the circumstances that are getting in the way of a person doing therapy, and can those environmental circumstances be dealt with? Does the person need help with transportation to therapy? Does the therapist need to speak to a school to advocate for a child to skip certain electives so they can come to therapy? Do you need a translator to help a person for whom English (or whatever language the therapy is being conducted in) is not their first language?
Components of DBT
In order to meet all these functions, comprehensive DBT has developed the following modes of therapy delivery: skills training group, individual treatment, DBT phone coaching, and a consultation team.
Group:
The DBT skills training group is focused on enhancing a person’s capabilities by teaching them behavioral skills. The group is run like a class, where the group leader teaches the skills and assigns homework for people to practice in their everyday lives. Typically, groups meet on a weekly basis for approximately two and a half hours. In standard outpatient DBT, it takes 24 weeks to complete the full skills curriculum.
Individual therapy:
DBT individual therapy is focused on enhancing a person’s motivation and helping apply the skills they have learned in group to the specific challenges and events in their lives. In the standard DBT model, individual therapy takes place once a week for approximately 60 minutes and runs concurrently with skills groups.
Phone coaching:
DBT phone coaching is focused on helping people generalize the skills they have learned to problematic situations happening outside of individual or group therapy. Patients can call the person doing the skills coaching — who could be the individual therapist or another member of the team — between sessions to receive coaching ideas at the times when they need help the most.
