Dialectical Behaviour Therapy
What is Dialectical Behaviour Therapy (DBT)?
A Dialectic is defined as “the existence or action of opposing social forces or concepts”. DBT was developed to support individuals who are often faced with dialectics in their life - for example, they love and dislike someone at the same time; they feel they need people in their lives but also have a strong sense of independence.
In DBT the core dialectic focuses on the treatment philosophy – it is about finding a way to develop both change (in your thinking, feelings and behaviour) and acceptance of who you are.
DBT was first developed by Marsha Linehan in 1980. She was working with individuals with high levels of self-harm and suicidality, who often were given the diagnosis of Borderline Personality Disorder (BPD – also known as Emotionally Unstable Personality Disorder), and she noticed that regular cognitive and behavioural strategies did not work with such individuals.
Bio Social Model:
The Bio Social model was developed to help explain the development of these Personality problems. The theory suggests that BPD is primarily a disorder of the emotion regulation system. Emotion dysregulation is considered to be due to two factors:
EMOTIONAL VULNERABILITY (BIO)
The person is emotionally vulnerable: Their body is very highly physically sensitive to emotions. This means that the person has a high sensitivity to emotional stimuli (they react quickly and have a low threshold for an emotional reaction, i.e. it doesn't take much), emotional intensity (emotional reactions are extreme and more dramatic than one would expect) and a slow return to baseline (reactions are long-lasting).
Difficulty regulating emotions means that the individual has a lack of skill in managing their emotions. They may act impulsively, without thinking through whether the action will hurt them/ others. They may focus on getting their immediate goals (often to reduce distress) met as this feels unbearable to them, which makes reaching longer term goals difficult.
There is no single cause for these two biological predispositions for BPD. For some, it could be hereditary but for others, there could be other acquired causes, e.g. during pre-natal, post-natal development.
ENVIRONMENTAL EXPERIENCES (SOCIAL)
The type of early environment that contributes to BPD is called “the invalidating environment”. This environment is typically the family environment but isn’t necessarily one in which a child is abused or neglected. Even the most well-intentioned families can be invalidating.
An invalidating environment is one in which a child’s communication of their private experiences is not met with understanding and compassion but erratic, inappropriate and extreme responses. Their feelings are not validated, but disregarded, punished or trivialised, and not viewed as valid responses to events. This tells the child that their thoughts or feelings are just plain wrong.
For example, if a child expresses upset, the family does not pay attention or tells her she’s making a big deal about it, they invalidate her inner experience.
Those who grow up in an invalidating environment learn to believe that their actions, thoughts, and feelings don’t matter. This can hinder their ability to recognise their own emotions and cause them to distrust their emotions. It also does not teach them to effectively regulate their emotions, problem-solve or form realistic goals for the future. The child learns that extreme emotional displays are necessary to get help, so moves between inhibition and extreme emotional states. They may later turn to substance abuse or self-harm as a way to better cope with and control their emotions.
What does therapy involve?
DBT developed to include a focus on four main areas, and these are addressed within skills groups:
Mindfulness: A focus on developing your ‘wise mind’ through a range of mindfulness exercises; focus on the here and now rather than allowing yourself to get stuck in the past, or worrying about the future.
Emotional Regulation: This module helps you to understand why we have emotions. It then looks at skills to be able to manage when you feel these, but also strategies to reduce the likelihood of them happening.
Distress Tolerance: This focuses on skills to help you manage when you are in a crisis – your emotions feel overwhelming and as if nothing will help. At such times, trying to use cognitive techniques is unlikely to work, so these skills are simple, behavioural strategies to help you manage. It also teaches the idea of radical acceptance, for when we can't change an upsetting situation or circumstance.
Interpersonal Effectiveness: This looks at developing skills in being able to communicate with others in an effective way – by making sure that you put your point across in an assertive, but non harmful way.
Full DBT therapy involves a number of components and should be completed by a team of therapists. These are:
Weekly individual sessions which focus on the individual discussing any life threatening, therapy interfering or daily living interfering problems. The individual is asked to identify specific problem behaviours which they then record on a weekly diary sheet. The individual session involves completing a ‘Behavioural Chain Analysis’ to explore the most problematic behaviour, and then a focus on agreeing on skills that could have been used to manage this.
Group skills sessions which focus on the four modules above. These are an opportunity to learn specific skills and start to apply them to yourself, whilst also learning from other people’s experiences.
Access to ‘emergency coaching’ outside of sessions, if you find yourself in a crisis. These are 15-minute telephone conversations with a focus on agreeing on strategies to manage.
The therapy team also have weekly ‘consultation’ (supervision) sessions to discuss the clients that they are working with and gain support.
There is a large evidence base for DBT as an effective treatment for BPD. It is mentioned in the NICE guidelines for Borderline Personality Disorder as an evidence-based therapy which works.
I am unable to offer Full DBT to clients at the moment. However, I am able to offer a DBT informed approach, which includes aspects of the individual and group sessions above. This would involve an assessment of your needs and an individualised plan developed with respect to which areas may be most beneficial to you. At present I am unable to offer emergency coaching outside of the session, however, I would always develop a keep safe plan with individuals which includes an agreement of how to access support in a crisis.
If you would like to know more about DBT, below are some youtube videos you may find interesting:
There are a number of Apps that also offer an introduction to DBT (I would recommend these being used alongside therapy):