Dialectical Behaviour Therapy

Dialectical Behavioural Therapy (DBT) is a type of psychotherapy (or talking therapy) closely related to Cognitive Behavioural Therapy (CBT), a very popular type of intervention. DBT differs from CBT as it focuses particularly on very intense emotions. These emotions can either be experienced very strongly, for a very long period of time, or both.
DBT is often used after other options (such as CBT or other talking therapies) have been tried first. This is because DBT is best suited to individuals experiencing otherwise treatment-resistant systems.

What is Dialectical Behavioural Therapy?

History of DBT

Marsha Linehan initially developed DBT to treat women struggling with dual diagnoses. A dual diagnosis occurs when someone has more than one mental health condition that requires treatment at the same time. However, DBT has a much more pervasive application than solely treating women. DBT, like other types of therapy, is not gender-specific, meaning it can be used to treat men, women and non-binary individuals. Linehan’s design of DBT was focused on the goal of establishing a form of support for ‘multiproblematic, suicidal’ individuals.

More specifically, Linehan was trying to establish a way to better support women with diagnoses of Borderline Personality Disorder, a condition that ‘severely impacts a person’s ability to manage their emotions’, which can frequently lead to impulsivity. This focus on strong feelings and impulsivity makes DBT a viable option for a range of individuals with varying diagnoses. It also means that, in practice, DBT is particularly helpful for treating individuals at risk of taking their own lives.

DBT: The basic  principles

Acceptance

Perhaps the most important element of DBT is the focus on acceptance. Linehan found that a lot of clinical research (and, therefore, practice) tended to look closely at how individuals can change how they think, feel and act. She then concluded that these types of therapy could lead to people feeling implicitly attacked, misunderstood and even invalidated. This can lead to poor treatment outcomes and even premature ending of therapy due to disillusionment.

Linehan believed, then, that a therapy based on acceptance could fill this niche. By accepting our thoughts and feelings, we can stop trying to fight them and instead begin to consider them with a cool, calm distance. This can help us to become more objective and establish some distance between our thoughts and our immediate realities. It can also allow people to feel more confident in rejecting particularly difficult thoughts and beliefs. Acceptance has since been established as a key component of emotional well-being and has also led to off-shoot forms of support, such as Acceptance and Commitment Therapy (ACT).

Mindfulness

Another key area in DBT is the use of mindfulness, the practice of staying present, being attentive, and trying to control our thoughts and feelings. Connecting acceptance and mindfulness leads to a range of practices that can allow us to feel more in control and emotionally aware – and, therefore, calmer. Cultivating this sense of calm is core to DBT practice. The goal is that this calm can act as a protective factor among those who may need it most.

What is DBT used for?

DBT has been shown to be especially effective in individuals presenting with an increased level of risk. When distress gets too intense or has been present for too long, then we can struggle to cope. This can lead to the development of unhealthy, potentially harmful coping behaviours.

In the clinical world, these kinds of behaviours are known as maladaptive. They can include:

• physically harming yourself (head banging, pulling hair, cutting or burning the self)
• engaging in disordered eating practices (such as restricting diet, binge eating or purging)
• drinking or using drugs
• spending large amounts of money
• avoidance of specific situations
• aggression of violence towards others
• engaging in unsafe sex
• absconding (running away)

Whilst the channelling of negative energy in an attempt to self-soothe is positive, there are ways to combat strong feelings without causing harm to yourself or others. DBT focuses on reducing the risk of engaging in harmful behaviours by:

• increasing awareness of alternative coping mechanisms
• helping to analyse the thought patterns that lead to harmful behaviours
• practising self-compassion.

Managing suicide risk

In some cases, maladaptive tendencies can turn into high-risk behaviours. This can include behaviours that could risk the health or life of an individual, either intentionally or otherwise. For this reason, DBT is often used when individuals are considered to have a high suicide risk. Over 700,000 people die by suicide each year. Suicide is the 4th leading cause of death in young adults (those aged 15 – 29). This indicates that suicide is a public health issue and illustrates the importance of interventions such as DBT, which aim to help people manage difficult feelings and suicidal urges.

DBT manages risk in several ways, including the development of emotional regulation techniques and the strengthening of interpersonal effectiveness.

Dialectical Behavioural Therapy: In theory

Acceptance is the cornerstone of DBT. However, within this framework, there are several key elements that provide the main structure for DBT. These elements are:

For example, your response to distress could be anger. Similarly, you could become over-reliant on a specific individual, which can lead to the development of codependent relationships. In order to keep these relationships flowing, we need to know how to connect with others. DBT gives us practical advice on how to engage with the people around us, including how to ask for help when we need it, as well as how to consider the effects of our actions on those around us. This gives us the tools we need to start nurturing ourselves through appreciating and maintaining our connections with others.

Dialectical Behavioural Therapy: In action

DBT will take place in scheduled appointments. Typically, you will work with the same therapist on each occasion in order for you to establish a positive working relationship. Outside of DBT, you may be asked to complete specific exercises that link to the discussions you have in session. This work outside of therapy can be invaluable in the sense that it allows the practice and application of specific DBT techniques.

Harm prevention in action

One of the key ways you will practise harm prevention is by keeping an up-to-date safety plan with you. It is important to have this easily accessible so it can be referred to in times of need. Your safety plan may include:

• potential triggers (for instance, being in a pub
• early waring signs (what you may be thinking or feeling in the pub)
• the risky behaviour this trigger may catalyse (relapsing, binge-drinking)
• alternatives for engaging with risky behaviour (talking to a friend about your feelings, leaving the pub, practising mindfulness)
• emergency contact details if you feel unsafe

Mindfulness in action

Almost all activities can be made mindful. If there is a particular hobby you enjoy spending time with, it may be worth speaking to your therapist to see how you can integrate mindful practice into your specific activities. If you would rather work from set activities, there are a range of recommended methods of practising mindfulness available.
These include, but are not limited to:

• Mindful colouring, art, or scrapbooking
• Mindful eating
• Mindful walks
• Mindful exercise
• Mindful listening
• Mindful gardening
• Body scans
• Observing your environment
• Mindful breathwork (honing in and focusing on the breath)
• Using mindfulness apps on your smartphone
• Listening to stories or other calming audio recordings
• Practising gratitude
• Daily journaling as a way of checking in with yourself
• Single-tasking (being fully present and focused on one task)
• Five sense observation: list things around you that you can see, hear, smell or touch
• Completing a puzzle
• Being compassionate to yourself (list things you like about yourself, or things you have achieved)
• Yoga

Interpersonal Effectiveness in Practice

DBT can be used in group and family therapy settings. This can offer a very helpful opportunity to begin practising interpersonal effectiveness in sessions. During group therapy sessions, you will have the opportunity to discuss specific situations jointly. A lot of people find that this group discussion can lead to the development of new skills and perspectives to use in the future. For example, if you spoke with peers in a DBT session about how they may deal with the trigger of being in a pub or restaurant setting, you may learn new ways of coping with this trigger in future. Similarly, you can share your experiences, increasing confidence and building positive relationships. A clinician will always mediate these discussions.

How effective is DBT?

The effectiveness of DBT will vary from person to person. This depends on a variety of factors, such as:

• the individual’s current needs
• their current ability to fully commit to therapy
• attendance
• openness and honesty
• engagement with DBT practices outside of sessions

DBT has been shown to reduce suicide risk; studies indicate far fewer instances of suicide attempts are recorded in treatment populations following engagement with DBT compared with prior to starting therapy.
Research has shown that a reduction in depression, dissociative and borderline symptoms can be identified as individuals go through the DBT process. Out of these individuals surveyed, between 35.5 and 38.5% were considered to have clinically recovered during their time in DBT.

DBT: The benefits

DBT is a viable option for many individuals dealing with intense, complex psychological distress associated with addiction and mental health conditions. DBT is particularly effective in the following areas:

• reducing levels of depression
• reducing levels of anxiety
• alleviating stress symptoms in the long term
• alleviating symptoms relating to trauma
• Reducing the risk of self-harm or suicidal ideology
• reducing the risk of cravings and thoughts of substances
• increases confidence and feelings of value
• increases social interaction and related skills

Evidence for the efficacy of DBT is strong across many demographics. DBT is an appropriate form of support for individuals from any walk of life, regardless of gender, race, sexuality or (dis)ability. It can also be a particularly tenable option for those dealing with complex or dual diagnosis, including individuals in treatment for substance addiction.

Using DBT for my addiction

If you or someone you know is grappling with mental health challenges or facing difficulties related to addiction, considering Dialectical Behavior Therapy (DBT) may prove beneficial. The primary objective of DBT is to assist individuals in gaining control during challenging moments.
DBT serves as a fundamental component of global mental health and addiction treatment strategies. Whether you choose inpatient or outpatient care, DBT can be tailored to your specific circumstances. Embracing Dialectical Behavior Therapy could mark a significant initial stride toward recovery, increased clarity, and a heightened sense of self-control.