Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy aims to help people who don't know how to deal with difficult emotions. People who benefit from DBT react with yelling, threats, or aggression in situations in a way most people would think is inappropriate. They feel misunderstood, invalidated, hurt, or angry, and don’t know what to do with feelings that seem to be too much and too big.

Reality is a matter of interpretation. Imagine you see your boyfriend buying jewelry, and when you meet up, he doesn’t even mention it. One person may think he is cheating and start accusing him, while another may think that he bought a birthday gift, and is keeping it secret. Neither really knows “the truth.” Dialectic means investigating the truth of an opinion. Humans immediately form rigid opinions from insufficient information. DBT challenges us to think through our interpretations, ask questions, and improve our emotional tolerance to life, as well.

DBT can help patients recognize their emotions, tone them down, and make choices that won’t ruin relationships. Its aim is to approach present behavior in a healthy way, not figure out past trauma. DBT wants to help patients figure out the now, and deal positively with it, so that they can heal the past from a position of strength.

Because the goal is to deal with the regulation of emotions in the present, DBT is the treatment of choice for Borderline Personality Disorder (BPD), where explosiveness, and oversized reactions are the hallmark. Patients with PTSD ,or eating disorders also benefit from DBT, because once emotions are better regulated, the person can face the trauma and pain of the past with better skills and acceptance. It is also important to include the family in skills training, so they can reshape the way they understand and validate their loved one’s feelings.

DBT teaches skills in four key areas:

• Mindfulness: Being present in the moment without dwelling in the past or predicting what the future looks like.
• Distress Tolerance: Increasing a person’s tolerance to the negative emotions that are part of life, and the skills to face them instead of avoiding them.
• Emotion Regulation: DBT teaches skills to handle difficult emotions that interfere with a person’s life.
• Interpersonal Effectiveness: Everyone needs the skills to communicate in a positive and assertive manner that supports self-respect, and builds up relationships.

In DBT you go to at least one group a week, and to individual therapy. There is 24 hour counseling by phone. In a challenging situation, you call your therapist, who coaches you through the skills you have learned. For example, you can call your therapist during an escalating confrontation. The therapist would guide you to breathe, relax, and walk you through techniques to de-escalate your emotions, and the situation.

The progression of the therapy is as follows:

• Enhancing capabilities. This means improving skills in the four areas we talked about above. We can learn these skills in an individual setting, or by studying and practicing them in group.
• Generalizing capabilities. The skills learned in group or individual therapy are translated to the patient’s real life. That’s where the phone coaching is helpful.
• Improving motivation and reducing dysfunctional behaviors. This is where the patient understands herself better, and finds reasons to live a better life. The patient records the events in the week in a diary card. They include acts of self care, frequency of outbursts, depression, etc. Then, in individual sessions, the therapist and patient talk about what effect these behaviors had on relationships and self esteem. They can investigate what situations led to negative behaviors and problems, and map a strategy for better responses.
• A treatment team. Being a good therapist is challenging. They also need the support of other experts to network and get advice. The DBT treatment team provides support, reevaluates, and helps implement the treatment plan so that the individual therapist can provide the best care possible.
• Structuring the environment. This means setting up a practice that promotes healing, and encourages the patient to structure their environment for positive change. For example, avoiding negative people or crowds, or places that trigger unhealthy behaviors and feelings.

DBT is a really hard form of therapy. Most people feel very uncomfortable being wrong, and DBT forces us out of our comfort zone by looking at our beliefs, and challenging our attitudes and behaviors. It makes us admit we may be reading situations incorrectly. The thing it does not do is invalidate our feelings. They are not judged or denied. Instead, we are taught what to do with them in a healthier manner. All the hard work of DBT is well worth it, because the improvement in self esteem, quality of life, and better relationships is priceless.