Dialectical Behavior Therapy (DBT)

Question 1

Historical Background of DBT

Answer 1

Originator: Dr. Marsha Linehan developed DBT in the late 1980s.

Purpose: Originally designed to treat individuals with Borderline Personality Disorder (BPD), especially those exhibiting suicidal behaviors.

Evolution: Over time, its applications expanded to treat other disorders and problems, such as substance dependence, eating disorders, and PTSD.

Question 2

Core Philosophy: The Dialectic

Answer 2

Dialectics: Involves holding two seemingly opposing truths simultaneously. In DBT, this often pertains to acceptance and change.

Balance: Clients are taught to accept themselves as they are while also recognizing the need for change.

Question 3

The Four Modules of DBT

Answer 3

Mindfulness: The practice of being fully present and aware in the moment without judgment. Derived from Zen Buddhist teachings.

Distress Tolerance: Techniques to tolerate and survive crises without resorting to self-destructive behaviors.

Interpersonal Effectiveness: Skills to navigate and foster effective relationships, assert one’s needs, and set boundaries.

Emotion Regulation: Strategies to understand, name, and change emotional reactions.

Question 4

Treatment Components

Answer 4

Individual Therapy: Weekly one-on-one sessions with a therapist to address personal challenges and progress.

Group Skills Training: Weekly group sessions to learn and practice the core DBT skills.

Phone Coaching: Between-session contact with the therapist to coach the application of DBT skills in real life.

Consultation Team: Therapists consult with a team of peers to maintain their own motivation and ensure effective treatment delivery.

Question 5

Chain Analysis

Answer 5

A core technique in DBT, this involves a detailed examination of events and circumstances leading up to target behaviors (like self-harm).

By understanding these chains of events, clients and therapists can identify intervention points to prevent or modify behaviors.

Question 6

The Bio-Social Model

Answer 6

Central to DBT’s understanding of BPD.

Biological: Some individuals have a higher biological reactivity to emotional stimuli.

Social: This reactivity can be exacerbated in environments that are invalidating or dismissive of the individual’s feelings and experiences.

Interaction: DBT posits that BPD emerges from the interaction of this biological vulnerability with an invalidating environment.

Question 7

Efficacy of DBT

Answer 7

Numerous studies validate DBT’s efficacy in reducing self-harming behaviors, hospitalizations, and improving overall functioning.

Found effective not just for BPD, but also for other disorders and challenges, as mentioned.

Question 8

Commitment and Validation

Answer 8

Commitment: Both therapist and client commit to the therapeutic process and the overarching goal of building a life worth living.

Validation: A key component of DBT, where the therapist acknowledges and validates the client’s experiences, feelings, and challenges. This builds trust and reduces client-therapist conflicts.

Question 9

Limitations of DBT

Answer 9

Requires a significant time commitment.

Therapists need extensive training and ongoing consultation.

May not be suited for all individuals or disorders.

Question 10

Modern Innovations and Adaptations

Answer 10

Proliferation: DBT principles are now incorporated in many settings, from schools to prisons.

Adaptations: New versions of DBT have been developed for specific populations, such as adolescents or individuals with eating disorders.

Question 11

Key Principles of Mindfulness

Answer 11

Observing: Noticing your environment, internal and external, without adding or subtracting from the experience.

Describing: Putting words to the observed experiences without judgment.

Participating: Engaging fully in the current activity.

Question 12

DBT Session: Introducing the “Mindfulness of Current Emotion” Technique

Answer 12

Therapist: Today, we’re going to practice a mindfulness technique called “Mindfulness of Current Emotion.” This skill helps us become more in tune with our emotions without becoming overwhelmed by them. It’s about observing our feelings without judgment. Are you okay with trying this?

Client: I’m a bit nervous, but I’ll give it a go.

Therapist: That’s perfectly normal. Remember, there’s no right or wrong way to feel during this exercise. It’s all about observation and acceptance.

Instructions:

Find a Comfortable Position: Sit comfortably in your chair with your feet flat on the ground. You can close your eyes if you’re comfortable, or keep them open, focusing on a spot in the room.

Take a Few Deep Breaths: Deeply inhale through your nose and exhale through your mouth a few times. This helps ground you in the present.

Identify Your Current Emotion: Ask yourself, “What am I feeling right now?” Try to label the emotion if you can – like sadness, joy, anger, or anxiety. If you can’t label it, that’s okay too.

Observe the Emotion: Notice where in your body you feel this emotion. Is there tension? Warmth? Cold? Tightness? Try to describe the physical sensations to yourself.

Avoid Judging: If you find yourself making judgments like, “I shouldn’t feel this way,” gently redirect your focus back to observing the emotion. This is about accepting whatever you’re feeling in this moment.

Duration: Spend a few minutes (typically 5-10 minutes) just observing this emotion and its physical manifestations.

After the Exercise:

Therapist: How was that experience for you?

Client: It was strange at first, but it made me realize that my anxiety feels like a tight ball in my chest. I’ve never really paid attention to it like that before.

Therapist: That’s a great observation. The more we practice this, the better we can become at recognizing our emotions as they arise, giving us more choice in how to respond to them.

Question 13

Key Principles of Distress Tolerance.

Answer 13

Definition: Techniques and skills to endure and navigate difficult situations without resorting to impulsive or harmful behaviours.

Distraction: Redirecting attention away from distress.

Self-soothing: Using the five senses to calm oneself.

Improving the moment: Using cognitive techniques to create a sense of safety.

Acceptance: Accepting the reality as it is.

Real-Life Example:
You’re stuck in a traffic jam and running late. Instead of escalating into road rage or an anxiety attack, you turn on soothing music, take deep breaths, and remind yourself that getting angry won’t make the traffic move faster.

Question 14

DBT Session: Introducing the “Distress Tolerance” Technique

Answer 14

Distress Tolerance skills in DBT are designed to help individuals cope with painful events by building resilience and providing new ways to soften the effects of upsetting circumstances. One of the commonly taught techniques in this module is the “TIPP” technique.

Therapist: When we find ourselves in a highly emotional state, it’s often hard to think straight or use our skills effectively. The “TIPP” technique is a distress tolerance skill designed to change our body’s physiology quickly, helping us to calm down. It stands for Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation. Would you like to try it?

Client: I’ve been feeling so overwhelmed lately. I’ll try anything.

Therapist: Alright, let’s go step by step.

1. Temperature (T):

Therapist: Changing your body’s temperature can help shock the system a bit, grounding you back to the present. A popular method is holding a cold pack or dunking your face in cold water. Do you have a cold water source nearby?

Client: I’ve got a cold water bottle here.

Therapist: Great. Hold it against your face, particularly under your eyes and on your cheeks. Take a few deep breaths. This mimics the “dive response,” a physiological response that helps reduce arousal.

2. Intense Exercise (I):

Therapist: Intense exercise can help burn off adrenaline and release endorphins, which are natural painkillers. Jumping jacks, running on the spot, or even fast-paced walking can help. Can we try doing some quick exercises?

Client: Okay, I can try a few jumping jacks.

3. Paced Breathing (P):

Therapist: This involves breathing deeply into your stomach. Try a count of 4 for inhaling, hold for 4 seconds, then exhale for a count of 4. This kind of breathing helps calm the body.

Client (after practicing): I feel a bit calmer now.

4. Paired Muscle Relaxation (P):

Therapist: This involves tensing and then relaxing different muscle groups in the body. For example, clench your fist tight, hold, then release and feel the relaxation. We can do this with different parts of the body.

Client (after practicing): That’s relaxing. I’ve never tried that before.

Therapist: The TIPP skills are best used when you feel extremely distressed and need to calm down quickly. They can be a bridge to then using other skills once you’re in a more manageable emotional state. How do you feel now after trying them?

Client: I feel more grounded and present. I think with practice, this could be a good tool for me.

Therapist: That’s great to hear. Remember, like any skill, it gets more effective with practice. The idea is to have a toolbox of strategies you can draw from when facing distressing situations.

Question 15

Key Principles of Interpersonal Effectiveness techniques.

Answer 15

Definition: Skills to navigate and maintain healthy relationships, assert one’s needs, and set boundaries.

Objective Effectiveness (DEAR MAN): Describing, Expressing, Asserting, Reinforcing, staying Mindful, Appearing confident, and Negotiating to get one’s needs met.

Relationship Effectiveness (GIVE): Being Gentle, Interested, Validating, and using an Easy manner to maintain relationships.

Self-respect Effectiveness (FAST): Being Fair, not Apologizing for no reason, Sticking to values, and being Truthful to maintain self-respect.

Real-Life Example:
A roommate constantly leaves dirty dishes around. Instead of letting resentment build or lashing out, you calmly (Describe) tell them what you’ve observed, (Express) how it makes you feel, and (Assert) ask if a cleaning schedule can be set. You (Reinforce) by stating this will make the living situation better for both.

Question 16

DBT Session: Utilizing “DEAR MAN” for Interpersonal Effectiveness

Answer 16

Interpersonal Effectiveness skills in DBT focus on assisting individuals to engage in effective actions in interpersonal situations, ensuring that they can prioritize their self-respect, maintain relationships, and achieve their objectives in interacting with others.

Therapist: Today, we’re going to explore a crucial interpersonal effectiveness technique called “DEAR MAN”. It’s a mnemonic that helps us remember the key components of assertively communicating our needs or saying no to others. “DEAR” is about the objective of getting what you want or saying no, and “MAN” is about keeping the relationship and self-respect.

Client: I’ve always struggled with asking for help, especially from my colleagues.

Therapist: That’s a common struggle. “DEAR MAN” can be a helpful tool to navigate such situations. Let’s break it down:

D - Describe:

Therapist: Start by describing the situation factually, avoiding judgmental language. Just state the facts.

Example:
“I’ve noticed that I’ve been staying late recently to finish the XYZ project.”

E - Express:

Therapist: Express your feelings and opinions about the situation using “I” statements.

Example:
“I feel stressed and overwhelmed because it’s been consistent.”

A - Assert:

Therapist: Assertively state what you need or say no clearly. Avoid beating around the bush.

Example:
“I need to ask for some assistance to manage the workload effectively.”

R - Reinforce:

Therapist: Explain the positive outcomes if your needs are met, providing a reward essentially.

Example:
“If I can get some help, I believe the project’s quality will improve and I’ll be able to maintain a healthier work-life balance.”

M - Mindful:

Therapist: Stay focused on your objective and don’t be sidetracked by irrelevant issues.

Example:
Even if colleagues bring up past favors, stay focused on the current issue and re-state your need.

A - Appear Confident:

Therapist: Use a confident voice, make eye contact, and avoid undermining words like “maybe” or “sort of.”

N - Negotiate:

Therapist: Be willing to give to get, offering solutions, and being open to alternatives.

Example:
“If it’s not possible to get assistance on all tasks, could someone at least help with data analysis?”

Client: It makes sense but feels a bit intimidating.

Therapist: Absolutely, it can be challenging initially, but like any skill, it becomes easier with practice. Would you like to try role-playing a situation using “DEAR MAN”?

Question 17

Key principles of Emotion Regulation techniques.

Answer 17

Definition: Techniques to understand, name, and change emotional reactions.

Identifying and Labeling Emotions: Recognizing emotions as they arise.

Reducing Vulnerability: Decreasing sensitivity to emotion triggers.

Increasing Positive Experiences: Engaging in activities that evoke positive emotions.

Opposite Action: Acting opposite to one’s emotional urges that aren’t aligned with one’s goals.

Real-Life Example:
Feeling rejected after not being invited to a friend’s gathering, you might initially want to isolate yourself further. Instead, recognizing this emotion, you decide on an Opposite Action: you call another friend for a coffee or engage in a hobby you love, changing the emotional trajectory.

Question 18

DBT Session: Introducing the “Check the Facts” Technique for Emotion Regulation

Answer 18

Emotion Regulation skills in DBT help individuals to understand, experience, and manage their emotions in a healthier way. A foundational technique in this module is called “Check the Facts.”

Therapist: A lot of our emotional reactions are based on our interpretations of events, rather than the events themselves. Sometimes, our interpretations can be skewed or based on assumptions. One of the techniques we use in DBT to help regulate emotions is called “Check the Facts.” It helps us validate whether our emotional reaction is appropriate for the situation. Would you be interested in exploring this?

Client: Definitely. Sometimes I feel like I overreact, and I don’t even know why.

Therapist: That’s a common experience. “Check the Facts” can be a helpful tool. Let’s break down how it works.

1. Describe the Emotion-triggering Event:

Therapist: Think about a recent situation where you felt an intense emotion. Can you describe it?

Client: My friend canceled our plans last minute, and I felt really hurt and angry.

2. Identify the Interpretation or Assumption:

Therapist: When they canceled, what went through your mind? What did you assume or interpret about the situation?

Client: I assumed they didn’t value our friendship and that they probably found something better to do.

3. Check the Facts:

Therapist: Now, let’s evaluate. Are there any facts that support your assumption? And are there any facts that disprove it?

Client: Well, they said they had a family emergency. But they’ve canceled a few times in the past, so it feels like a pattern.

Therapist: It’s important here to differentiate between past events and the current situation. While past cancellations might have influenced your feelings, right now, we’re focusing on the recent cancellation due to a family emergency. Based on this fact, is your emotional intensity and reaction fitting the situation?

4. Determine if the Emotion and its Intensity are Justified:

Client: Given the family emergency, I guess my intense anger might not be justified this time. I still feel upset about the past cancellations, though.

Therapist: That’s valid. The goal here isn’t to invalidate your emotions but to help you align them more with the current facts. It sounds like there might be two issues: the past pattern and the recent cancellation. Addressing them separately might be beneficial.

5. If Emotion is Not Justified, Try to Change the Emotion:

Therapist: Since the intense anger might not fit the current situation, let’s explore techniques to reduce it. This could include opposite action, where you act opposite to your emotional urge, or self-soothing techniques.

Client: I see how my assumptions played a big role. Checking the facts seems helpful.

Therapist: It’s a powerful tool, especially when our emotions feel overwhelming. With practice, it can help in discerning when our reactions are based on facts and when they might be influenced by past experiences or assumptions.

Question 19

Initial DBT Session example

Answer 19

Therapist: Welcome. I’m glad you decided to come in today. Starting therapy can be a big step, and I want to make sure you feel comfortable and understood. Before we delve in, do you have any initial questions or concerns?

Client: Not really. I’m just… I’ve heard DBT can help with what I’m going through.

Therapist: It’s a strong therapeutic approach, especially for individuals struggling with emotional regulation, self-destructive behaviors, or interpersonal difficulties. To begin, could you share a bit about what brought you here?

Client: I’ve been feeling really overwhelmed lately. My emotions are all over the place, and sometimes I act impulsively just to feel something… or feel nothing. I also have trouble maintaining friendships.

Therapist: Thank you for sharing that with me. It sounds like you’ve been experiencing a lot of intense emotions and challenges in your relationships. DBT is designed to help individuals build skills in four main areas: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness. The goal is to provide tools to manage emotions, tolerate distress, and improve relationships.

Client: That sounds like what I need. But how does it work exactly?

Therapist: DBT combines individual therapy sessions with group skills training. In our individual sessions, we’ll focus on the challenges you face daily, exploring patterns and applying DBT skills. The group sessions are like a classroom setting where you and others learn and practice the skills together.

Client: Group sessions? I’m not sure how I feel about that.

Therapist: That’s a common concern. It’s worth noting that many people find the group sessions beneficial because they realize they’re not alone in their struggles. However, the choice is ultimately yours, and we’ll work together to determine the best approach for you.

Client: Okay. I’m willing to give it a try.

Therapist: That’s a great attitude. As we move forward, it’s crucial for us to establish a strong working relationship. It’s okay to ask questions, share concerns, or let me know if something isn’t working for you. Our goal is to collaborate and find ways to support your growth and well-being.

Client: I appreciate that. I just want to feel better.

Therapist: And that’s what we’re here for. As we wrap up today, I’ll provide you with a brief overview of mindfulness, the foundational skill in DBT. We’ll be diving deeper into this and other skills in our upcoming sessions.