Ailey O’Toole
   Staff Writer

Marsha Linehan once said, “Borderline individuals are like people with third degree burns over 90 percent of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement.”    

Dialectical behavior therapy (DBT) is a type of cognitive behavioral psychotherapy (a.k.a. talk therapy or counseling) developed in the late 1980s by psychologist Marsha Linehan to treat chronically suicidal patients with borderline personality disorder (BPD).

It is still primarily used to treat BPD but has now been developed to also treat behavioral disorders involving emotional dysregulation (e.g. substance abuse in individuals with BPD; binge eating disorder) and for treating people with severe depression and associated suicidal thoughts.

DBT emphasizes the psychosocial aspects of treatment. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward emotional situations.

DBT suggests that some people’s arousal levels in interactions with significant others, family and friends can increase far more quickly than an average person, can attain a higher level of emotional stimulation and can take a significant amount of time to return to baseline.

Individuals, who are diagnosed with BPD experience extreme swings in emotions, see the world in shades of black and white and seem to always be jumping from one crisis to the next.

Because few people understand such reactions – most of all their own families which created childhood that emphasized invalidation – they don’t have any methods for coping with the symptoms described above. DBT helps to develop the needed coping mechanisms.

These are the main characteristics of DBT:

·      Support-oriented: helps patients to identify strengths and build on them

·      Cognitive-based: helps recognize thoughts, beliefs and assumptions that make life harder, such as “I have to be perfect at everything” or “If I get angry, I am a terrible person,” and then helps to learn more beneficial ways of thinking, such as “I don’t need to be perfect at things for people to care about me” or “Everyone gets angry; it’s a normal emotion.”

·      Collaborative: requires constant attention to relationships between clients and staff; during sessions, patients are encouraged to work out problems in relationships and therapists assign homework assignments, such as practicing new ways of interacting with others or working to sooth oneself when upset. The therapist helps the patient learn, apply and master the DBT skills.

DBT has two components: (1) individual weekly psychotherapy that emphasizes problem-solving behavior for the past week’s issues and troubles that have arisen since the last session and (2) weekly group therapy sessions, generally two and a half hour sessions that are led by a trained DBT therapist where patients learn skills from different modules.

Self-injurious and suicidal behaviors take first priority during individual sessions, followed by behaviors that may contradict the emotional progress achieved during therapy.

These sessions in DBT also focus on decreasing and dealing with post-traumatic stress responses caused by previous traumas, while helping to enhance a patient’s own self-respect and self-image.

The therapist navigates these sessions by actively teaching and reinforcing adaptive behaviors; the emphasis is on teaching patients how to manage emotional trauma rather than reducing or taking them out of crises.

During weekly group therapy sessions, patients learn coping mechanisms from one of four modules: mindfulness, interpersonal effectiveness, distress tolerance and emotion regulation.

1. Mindfulness

Mindfulness is the practice of being fully aware and present in this one moment; it is considered the foundation for the other skills in DBT because it helps patients accept and tolerate the powerful emotions they may feel throughout the course of treatment.

Mindfulness skills are derived from traditional Buddhist practices, though the version presented in DBT does not involve any religious or metaphysical concepts. Mindfulness involves 3 “what” skills: Observe, Describe and Participate, and 3 “how” skills: Non-judgmentally, One-mindfully and Effectively.

2. Interpersonal Effectiveness

Interpersonal effectiveness is about how to tolerate pain in difficult situations not how to change it. These response patterns are very similar to those taught in assertiveness and interpersonal problem-solving classes. Strategies include asking for what one needs, saying no and coping with interpersonal conflict.

Individuals with BPD generally posses good interpersonal skills, but problems arise in applying those skills to specific situations. A patient may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation but may be incapable of generating or carrying out a similar sequence when analyzing his or her own situation.

3. Distress Tolerance

Most mental health treatment programs focus on changing or avoiding distressing events and circumstances. Professionals have paid little attention to strategies that accept, find meaning for and tolerate distress. DBT emphasizes skillfully learning to bear pain.

Distress tolerance skills are a natural extension of mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. This does not mean a patient is expected to approve of the situation: acceptance of reality is not approval of reality.

Four sets of crisis survival strategies are taught during the distress tolerance module: distracting, self-soothing, improving the moment and thinking of pros and cons. Acceptance skills include radical acceptance, turning the mind toward acceptance and willingness versus willfulness.

4. Emotion Regulation

This module is about how to change the emotions you want to change. Borderline and suicidal individuals are emotionally intense and labile – frequently angry, intensely frustrated, depressed and anxious.

Dialectical behavioral therapy clients benefit from help in learning to regulate their emotions.

Dialectical behavior therapy skills for emotion regulation include:

Identifying and labeling emotions

Identifying obstacles to changing emotions

Reducing vulnerability to “emotion mind”

Increasing positive emotional events

Increasing mindfulness to current emotions

Taking opposite action

Applying distress    tolerance techniques

DBT therapists can be hard to come by because they are so intensely and specifically trained. However, Psychology Today has a great database of DBT therapists in Greensboro.