Dialectical Behaviour Therapy

Dialectical Behaviour Therapy (and why it stands out among the rest)

Marsha Linehan

Described as incorporating cognitive behaviour techniques, DBT uses daily life skills, mindfulness practice, emotion understanding and regulation, tolerance to negative occurrences, building interpersonal skills and mostly importantly, acceptance. DBT is commonly used in one-on-one and group therapy sessions. Depending on the program, severity of mental illness and often, finances, the increase or decrease of one-on-one therapeutic sessions happens, while group programming in often weekly for outpatient and more often for inpatient treatment. Often referred to for “hard to treat” patients, DBT takes an introspective analysis into one’s behaviours, thoughts, feelings/emotions, trauma, and experiences typically on a daily basis – with the use of scale rated diary cards.

At 17, Marsha Linehan, Ph.D. spent over two years in a Psychiatric Facility for her habitual self-harming and other self-destructive behaviours. She was diagnosed with Schizophrenia and was considered a “very disturbed” patient. That was 1961; today she is considered to have Borderline Personality Disorder, a misunderstood condition characterized by inappropriate emotions and self-destructive urges and actions. Her experience, which she has only recently come forward about, lead to her education path in Psychology and the creation of Dialectical Behaviour Therapy (DBT).

Being accountable for every thought and action is what makes DBT shine in treating challenging clients. One must be ready for the change and commitment, a lot of uncomfortable thoughts, feelings and behaviours adapt and typically decrease or stop through this process. Alongside Borderline Personality Disorder (BPD), Dialectical Behaviour Therapy is used to treat self-harming, eating disorders, suicidal ideation, depression, anxiety, OCD and many combinations of the mentioned and others.

All techniques have been acquired through the Pinki Perspective and Fulton State Hospital uploads of DBT worksheets and the Dialectical Behaviour Workbook by Marsha Linehan et al. with an in depth understanding of the material through personal experience and skills applied to research.

 

Dialectical Thinking and Wise Mind

The concept of dialectical thinking is that every thought, opinion, emotion and thus behaviour all have two sides to their story, nothing is one sided – even things that appear to be opposites. Dialectical thinking allows one to see the pros and cons, the truths and falsehoods, the “good and bad” emotions and the wanted and unwanted behaviours. Think of using the language “both-and” rather than “either-or” – it is inclusive to the two sides.

Much like dialectical thinking, having a wise mind incorporates both sides of your mind – the emotional side and the rational side. The rational side is reached through dialectical thinking and the emotional side is better understood through the emotion regulation tools and theories. These ways of thinking are not easy and can be very challenging for people to grasp, practice and successfully implemented.

Mindfulness, Nonjudgmental Stance, and Radical Acceptance

Mindfulness within DBT emphasizes on balancing the wise mind, an understanding of the reasonable mind and the emotional mind and how they impact each other. Observing emotions, acknowledging these thoughts, not giving them power/meaning and letting them go allow one to move passed any ruminating or destructive thinking. This could be stating “the thought that I am stupid just came into my mind”; after a while these thoughts will enter your mind but they will not determine your mood or how you perceive yourself. Though it is common with people who have mental illness to ‘want the thoughts to stop’, knowing that most will never stop, but they will reduce is volume, strength and occurrence can be a challenging and relieving thing for that person to hear. With certain mental illnesses there is a high chance of negative and destructive self-talk in aim to help cope and soothe someone from emotional situations, and being able to gradually take these thoughts/voices without letting them control or impact one’s life and behaviours can be life changing.

Mindfulness is broken down into How Skills and What Skills, and give someone the skills to being aware in any moment, of both positives and negatives, not having judgments to any, and looking at effective ways to notice, check and potentially change emotions, thoughts and behaviours. The “What” skills are a practice regarding what one does to take control of their mind – ruminating thoughts, negative thought patterns and destructive self-talk.

  • How Skills: one-mindfully, non-judgmentally, and effective.
  • What Skills: observing, describing and participating

Nonjudgmental Stance

Everyone has judgments about one thing or another; what matters for behavioural and emotional change is considering the judgments that one gives power to. One’s body, one’s diet, one’s self worth, self-concept and self talk are all vital judgments impact one’s mental health. Concepts of a nonjudgmental stance are not to evaluate, but to take your personal opinions away from the facts, accept each moment, and not to judge any judgments. When it comes to oneself, or other people, just let it be, if one cannot be positive or even neutral about it, do not give it thoughts/power. This is not easy. Even with practice it can be challenging. Certain topics, conversations, people, food, anything really can make being nonjudgmental (and accepting) become tedious, unsatisfying and feelings of ineffectiveness.

DBT has tools for practicing nonjudgmental stances – it looks at what judgments are, expectations, the benefits and faults of having judgments and most importantly, acceptance and letting go of judgments. An adaptation of Marsha Linehan’s Practicing Nonjudgmental Stance worksheet asks the following questions as practice for turning a judgment about something into acceptance or without judgment.

  1. Identify a judgment about yourself, someone else, or some situation.
  2. Describe your reasons for letting go of this judgment.
  3. Replace the judgments with descriptions of facts, consequences and/or your preferences about this.
  4. Practice accepting the nonjudgmental descriptions and letting go of the judgments. Identify any works, actions (eg relaxation), body postures or imagery that helps you let go.
  5. Remember not to judge your judging! *
  6. Describe any changes you noticed in your acceptance or your emotion as you practiced nonjudgmental stance.
    *Enter any judgments about judgments here

Radical Acceptance

It is acknowledging what is (not what the mind says); it is not the same as judging it as good; freedom from suffering requires acceptance from within what is; it is loving-kindness: kindness brings kindness – its uplifting energy that will weaken the power of a judgmental mind that keeps you stuck. Radical acceptance is a choice: to act a certain way in any given situation. Reality acceptance believes that pain + non-acceptance brings suffering, and that mental and most physical pain can be reduced with that mindset.

Few of us ever live in the present.
We are forever anticipating what is to come or remembering what has gone.”
-Louis L’Amour

There are several ways of changing one’s ability to accept reality and they including facing and changing a rejecting mindset (think accepting) and coming from a place of trying to avoid reality with behaviours and thinking patterns; willingness is another factor for acceptance, and that is just being willing to be apart of this world and coping with what one knows into being able to do what needs to be done to make it, even if it is day by day. Acceptance is something that is one of the more challenging sides of D.B.T, many people with mental illness and negative coping mechanism come with a stance of ‘why me’ and all the various connotations – this mindset is challenging to break, especially when behaviours and thinking reinforce it. Being accepting of life takes a lot of awareness and practice to continually gain an acceptance understanding. Radical Acceptance aims to encourage an acceptance approach with the saying “with open hands and a half smile”: open hands is letting the world into our space and the half smile can trick the brain into thinking it is happier and more content than one may be feeling.

While some people prefer having their hands open and in a welcoming stance, others prefer their hands facing down typically resting on their thighs.


Willingness

When it comes to changing one’s behaviours, thinking and modifying their emotions, discovering the difference between being willing and willful will increase one’s success. Looking at the difference between the words willful is typically a describing word for one being intentional or determined, while willingness is one being ready to do something. They are quite similar in their definitions but the subtle differences are major when it comes to implementing change. Within the concepts of DBT, willingness is composing the Wise Mind, awareness and acceptance and doing what is needed – and sometimes one is only capable of doing what is just needed. Willfulness does not take into consideration awareness and acceptance, it is wishing and wanting change or for discomfort to stop but not making those necessary steps under the wise mind, radical acceptance and other skills like distress tolerance.

 

Emotion Regulation

Emotional Regulation is a main component of the DBT theory and practice; gaining an understanding and control of your emotions will help be able to implement and maintain emotion and behaviour changes. Through emotion regulation one will gain insight and skills to understanding their emotional experience, be able decrease emotional vulnerability and suffering making it a little be easier to get through the moment. Sometimes it is really hard to let go of a certain situation or a particular hurt, especially when emotions are involved. Understanding emotions allows one to identify emotions by observing what emotions are coming through and what is happening in the body and describing them – brining words to the experience. Regulation is also about noticing what emotions do for you and whether or not these emotional responses are effective by looking and the length and intensity of the emotional experience.

Dialectical Behaviour Therapy promotes healthy emotions through acceptance and nonjudgmental stance. DBT states that emotions/feelings just are (not good nor bad), the difference between having emotions and acting on emotions, understanding that emotions come and go and acting on them is not always necessary – just recognize – and know that emotions are not facts. And though one may wish to never feel again, emotions are something one cannot just get rid of – however there are those who numb out, dissociate or have low emotional recognition and regulation skills and thus may have lower emotional responses or understanding. DBT recognizes that emotions have three jobs: to help communicate, motivate and validate – all of these are necessary when changing and healing oneself.

When decreasing emotional sensitivity, one learns how to stop unwanted emotions from starting in the first place by implementing strategies that promote positive experiences and a sense of purpose. This also gives someone the chance to think about their emotions ahead of time – without ruminating.

Remember your ABCs

A: accumulate positive emotions
B: build mastery (do something difficult but 100% possible)
C: cope ahead of time with emotional situation; thinking head and planning for ways a situation could go.

PLEASE and VITALS or STRONG

There are times where emotions, thoughts and mental illness symptoms can almost feel too much to bear, and DBT has two acronyms for aiming to reduce vulnerability and suffering when it comes to emotions and thus also thoughts and behaviours: treat PLASE and VITALS.

Treat
   Physical
iLlness
   Eat balanced meals
   Avoid mood-altering drugs
   Sleep balanced
   Exercise
Validate
Imagine
Take small steps
Applaud yourself
Lighten your load
Sweeten the pot

Some workbooks or therapist will use another method of combining treat PLEASE and VITALS in remembering to stay STRONG.

             Sleep as much as needed – not too much or little
             Take medication your doctor prescribes (and take care when sick)
             Resist using street drugs or alcohol
             Once a day, do something that gives you a sense of control
             Nutrition – eat a balanced diet without emotions controlling
             Get exercise – 20 minutes a day helps improve one’s mood

Emotional Response: the 3 things

Emotional situations are challenging and can impact someone’s ability to cope. When changing emotional responses to situations, one must do three things:

  1. Check the facts: does the response fit the situation?
  2. Opposite action: acting the opposite to the emotion will decrease the intensity of the emotion one is hoping to cease.
  3. Problem solving by observing and describing the emotion/situation, checking the facts and looking at what are realistic short-term goals.

 

Crisis Response and Being In the Moment

Distract yourself

ACCEPTS moments as what they are, but to help you through rough thoughts there are some techniques:

Activities – do something
Contributions – volunteer
Comparisons – to those less fortunate
Emotions – act the opposite
Pushing away – do not think about painful aspects, for a while
Thoughts (other) – count to ten, replay a scene from a movie in your head
Sensations – hold ice in your hand, very hot-cold shower, elastic band on wrist

 Self-Sooth with the 5 Senses

Vision: view beautiful things
Hearing: listen to favourite songs or nature; call 1-800 number to connect with someone
Smell: lotions, perfumes; baking
Taste: mindfully enjoy your favourite food or drink
Touch: bath, comfy clothes, pet a furry friend; whatever is soothing

IMPROVE the Moment

During moments of distress and high emotions use the acronym IMPROVE to improve the moment and begin feeling better, even for a brief time.
Imagery – your own fantasy world that is calming and beautiful; breathe out the hurt
Meaning – find meaning or value in the pain: in spite of… I am doing…
Prayer: open your heart to a supreme being; ask for strength to bear the pain in this moment
Relaxation: muscle relaxation; very cold/hot bath, exercise
One thing in the moment: focus on only one thing, put your mind in the present
Vacation (brief): get away if possible; pull the covers over your head for 20minutes, unplug for a day
Encouragement: cheerlead yourself, “I’m doing the best I can do”

Pros and Cons

Looking at the benefits and negatives of tolerating and not tolerating distress and/or acting impulsively. One can also look at pros and cons when it comes to short term and long-term goals, relationships, situations etc.

 

Interpersonal Skills

When addressing one’s behavioural and emotional changes, more often than not, these factors are impacted by those we have relationships with, random people we interact with on a daily basis and then these interactions may be analyzed, judged and given emotions to. Most people are impacted positively and negatively by interactions with others and DBT implements Interpersonal skills to help one get what they are wanting, maintaining good relationships and of course loving and respecting one’s self – we have all heard the saying how can you love someone else if you cannot love yourself.

DEAR MAN

For getting what one wants, DBT uses the acronym DEAR MAN. The DEAR consists of describing the situation, expressing one’s feelings and opinions, asserting oneself by asking questions and saying no when necessary and finally, reinforce (or reward) through consequences. The usefulness of these tactics will depend on the situation and one is hoping to gain. MAN refers to staying mindful and maintaining your position (it also includes ignoring distractions and rudeness), appearing confident, and negotiate if necessary.

GIVE

The acronym for keeping relationships is GIVE. When interacting with others, especially if you are trying to gain something it is imperative to be gentle – no attacks, threats or judgments. Ensure that you are acting interested and actively listening to the person by validating their feelings, wants, opinions etc. The final part is to have an easy manner: smile, be light-hearted.

FAST

Finally, when it comes to having a good relationship with one’s own self, to look at respect and confidence, DBT implements FAST: being fair to yourself and others, not overly apologizing, sticking to one’s own values and being truthful to yourself and about yourself.

 

Depending on the day (and thoughts and emotions) this could be absolutely ideal or absolutely dreadful and draining.

There are going to be times, days, weeks, sometimes longer, when interacting with others or when being kind to oneself seems too hard, and they will happen. Factors that reduce interpersonal effectiveness reflect on one’s skill level for the situation, personal myths and beliefs, the emotional mind, indecisiveness about what one asks or even if to ask at all and the environment – the factors or people that will not let one succeed.

 

Daily Diary Card

A component of Dialectical Behaviour Therapy’s success is the use of dairy cards – and not just any diary card, it is an in depth look at every skill, whether it was thought about, practiced and/or implemented; there are personal goals applied to the diary card depending on mental illness and behaviours wanting changed – the diary card is adaptable throughout one’s entire recovery. Some diary cards, like the example below, will have self-harm and/or suicidal ideations already written into the daily rating scales. The fact that these daily accounts are so thought out, immensely detailed and relatively easy to understand make these cards ideal to fill out on daily basis – that is, when one is willing and in a state of mind that allows them to recall their daily tasks, thinking and behaviour patterns. And, of course, your daily emotion and feeling check ins.

As you will see, the slots for personal therapeutic goals are established between client and counselor with potential family and legal input, depending on the situation. Deciphering the skills used through urges and actions of a behaviour, like bingeing, purging, looking at daily life skills (nourishment and hydration, bathing, brushing teeth and hair, taking care of daily chores and commitments), self-pitying behaviours, confidence, almost anything, will make someone be aware of everything going on leading up to the thoughts and actions of the behaviour. Negative self talk and knowledge of caloric information when eating can easily lead to engaging of purging-like behaviours; or not getting out of bed, bathing, eating for days at a time can have detrimental effects on the mind and body when aiming to recover or implement changes.

Here is an example of a weeklong daily diary card. It is split between two pages:

  1. Emotions/Feelings, Acceptance, Self-Harm etc, and one’s personal therapeutic goals are entered in any of the four blank slots in the middle of the page. There are also notes for certain behaviours, incidents, accomplishments and successes.
  2. D.B.T skills used on a daily basis. This card has a quick explanation of each of the specific tool and a rating scale on how the skill was thought about, implemented or practiced and it’s effectiveness.



The Desire and Choice to Implement Change

Transtheoretical Model: the Stages of Change

The Transtheoretical Model (TTM) created in 1983 by DiClemente and Prochaska implements the Stages of Change through a biopsychosocial model that considers behavioural changes across all three environmental and genetic factors. The model’s three components are biology (body and physiology), psychology (brain and mind) and social (environmental, relationships); the biopsychosocial model is relational, implying they are all able to impact each other. Behaviour modification happens in a relatively linear process with people able to regress and progress depending on their ability to transition through resistance and life changes. There are times where regression will lead to a relapse, even after some time and great progress has been made. Many factors impact someone’s regression and those same factors will play a key role in their current and future progress. TTM is implemented in a variety of settings from addition treatment, mental illness recovery, a broad range of therapies, parental abilities and behaviour growth.

 

The Process of Change

Pre
Contemplation
Often thought as being not ready, individuals are not thinking about changing the unwanted behaviour. There are four Rs considered the reasons behind precontemplation – they are listed below under Resistance.

Depending on the environment and circumstances surrounding the change, certain timeframes may be used in assessment of precontemplation. Sometimes they are unable or unwilling to be self aware that there is a chance they not be given or have the information about the consequences of their behaviour.


Resistance Reluctant: lacking knowledge or desire to change. They may be unaware of problems or consequences

Rebellious: also could be considered resistant. They are typically only interested in their opinions and decision-making abilities.

Resigned: may be overwhelmed or have lost hope. Typically they have tried many times to control the unwanted behaviour.

Rationalization: justification of why the unwanted behaviour is only an issue for someone else and not an issue for the person.


Contemplation Individuals are getting ready, gaining awareness of the problems and consequences of the unwanted behaviour and may be interested in making changes. Ambivalence is quite high in this stage and individuals are often stuck and aware of both options: changing behaviour and maintaining behaviour. In regards to treatment, many helpers will work with the individual in assessing the benefit and consequences of both sides; encompassing all aspects of behaviour change is key.


Preparation Individuals have become ready, though some ambivalence may be present – they have decided to change their behaviour. Preparation is also considered determination, as there are many options, decisions and strategies to go through. Typically a Plan of Action has been established prior to moving forward; this can be done with professional helpers or through a self-help approach.


Action Individuals are ready to implement their Plan of Action. Some may have entered into treatment, counseling or taken on recovery meetings. Change has been observable. Sometimes general reduction or harm reduction techniques will be implemented as action steps, later to be revised as completely stopping the behaviour.


Maintenance If the Action stage has been positive and consistent for some time, individuals are considered to have implemented lifestyle changes and their commitment is quite obvious. Maintaining behaviours can be very challenging, especially depending on the habitualness and the ways behaviours are used to cope for emotional responses and emotional reactivity.


Relapse Relapse happens during behavioural changes; it may be a “slip” or where one fully resorts back to coping with the unwanted behaviour. The purpose of relapse is to facilitate learning and change – throughout the whole stages of change, one is learning a lot about themselves, how they cope and their resilience. One would be encouraged to re-enter the stages, focusing on problem solving and accomplishments.


Similar to topics that Dialectical Behaviour Therapy draws to, the Transtheoretical Model of Change insists on ten processes looking at thinking and feelings as one, and behaviour as another (listed respectfully). The following look at areas such as fact checking, awareness of yourself, others and the interactions, thoughts and feelings and looking at ways to feel good.

  1. Consciousness Raising
  2. Dramatic Relief
  3. Environmental Reevaluation
  4. Self Reevaluation
  5. Social Liberation Process
  6. Self-Liberation
  7. Counter Conditioning
  8. Helping Relationships
  9. Reinforcement Management
  10. Stimulus Control

Take a look:
Psych Central’s article on Carlo C. DiClemente and J. O. Prachaska’s Stages of Change
American Family Physician’s research article A ‘Stages of Change’ Approach to Helping Patients Change Behaviour by Zimmerman, Olsen and Bosworth.

The Readiness to Change Ruler

Looking at the behaviour one is wanting to change, they could assess their readiness using the scale and questionnaire below. The questions are quite thorough having one examine what is successful, challenging and what would be best to maintain change. Though change does not always feel easy or encouraging, change is a process, it has stages and it is something that can have a wonderful impact on one’s life.

Are you not prepared to change, already changing or somewhere in the middle?

          Not Ready for Change                                                                                                 Ready for Change

If the person’s mark is on the left of center:

  • How will you know when it is time to think about changing?
  • What signals will tell you to think about making a change?
  • What qualities in yourself are important to you?
  • What connection is there between those qualities and not considering a change?

If the person’s mark is near the center:

  • Why did you put your mark there and not closer to the left?
  • What might make you put your mark a little further to the right?
  • What are the good things about the way you are currently trying to change?
  • What are the things that are not so good?
  • What would be a good result of changing?
  • What are the barriers to changing?

If the person’s mark is on the right of center:

  • What is one barrier to change?
  • What are some things that would help you overcome this barrier?
  • Pick one of those things that could help and decide to do it by ____________

If the person has taken a serious step in making a change:

  • What made you decide on that particular stop?
  • What has worked in taking this step?
  • What helped it work?
  • What could help it work even better?
  • What else would help?
  • Can you break that helpful step down into smaller parts?
  • Pick one of those parts and decide to do it by __________________

If the person is changing and trying to maintain that change:

  • Congratulations! What’s helping you?
  • What else would help?
  • What makes it hard to maintain the change?

If the person has relapsed:

  • Don’t be hard on yourself. Change is hard and it may take time.
  • What worked for a while?
  • What did you learn that will help you when you give it another try?

 

Consideration: Maslow’s Hierarchy of Needs (Rights)

What about when one is ready for change, but there are barriers or basic needs not met? The ability to promote change in oneself and in the community is through assessing where one is standing with their basic human needs and human rights. There are many areas regarding basic needs that are not being met in today’s society – extreme poverty, no green space, overscheduled and underplayed children, inadequate nutrition and overworked parents and individuals feeling trapped and hopeless. Maslow’s hierarchy of needs is a great assessment tool for looking at where someone is before other aspects of their life can be addressed.

Needs are met starting from the basic needs (steps 1 and 2) and moving upwards towards step 8.

Self-fulfillment
Needs

8

Transcendence Needs

Helping others to achieve self-actualization

7

Self-actulization Needs

Realizing personal potential, self-fulfillment, seeking personal growth and peak experiences
6

Aesthetic Needs

Appreciation and search for beauty, balance, form

Psychological Needs

5

Cognitive Needs

Knowledge and understanding, curisosity, exploration, need for meaning and predictability

4

Esteem Needs

Achievement, mastery, independence, status, dominance, self-respect, respect from others

3

Belongingness and

Love Needs

Friendship, intimacy, trust and acceptance, receiving and giving affection and love. Affiliating, being part of a group
Basic Needs 2

Safety Needs

Protection from elements, secruity, order, law, stability, freedom from fear

1

Physiological Needs

Air, food, drink, shelter, warmth, sex, sleep

As it shows, many mental health condition would impact all of Maslow’s needs. Maslow was interested in the potential that people posess and the ways in which they will go abou meeting these needs. The focus on peak experiences drives a person towards continually finding feelings of excitement and bliss; when the mind is not in the best state, it can be hard to see what causes these positive emotions. Behavioural habits like restrictive eating and purging will cause many areas to be effected in negative ways – malnurtition, brain fog, low self esteem and self worth, isolation, and negative perceptions. People struggling with mental illness typically have a harder time having peak experiences due to the neurochemical changes in the brain and the physical and mental exhaustion that comes with most mental illnesses. When one is ready for change, but these barriers impact one’s ability to gradually move around the hierarchy of needs, it is chalennging to determining ambivalence, driving forces and habits that come with change.