What is DBT?
Dialectical behavior therapy (DBT) was developed by Marsha M. Linehan, from
the University of Washington, originally to treat people who were chronically
suicidal. These people often found standard Cognitive Behavioural Therapies
invalidating and supportive couselling validating but it did not affect enough
change. DBT combines Cognitive Behavioural Techniques (CBT) with Eastern meditation
and Dialectics and has been shown to be effective not only for the chronically
suicidal, but also for a range of disorders where emotional dysregulation is
involved such as depression and substance abuse.
How is treatment structured?
DBT treatments use a group and individual treatment in parallel. The weekly
group sessions teaches specific skills; mindfulness, interpersonal effectiveness,
emotion regulation and distress tolerance skills. The individual thereapy focuses
on issues that have come up during the week that require immeadiate individual
attention such as setbacks or therapy interfering behaviours as well as working
to improve skill use.
Emotion dysregulation is viewed as a joint outcome of biological disposition
and environmental context, and the transaction between the two during development.
This systemic dysregulation is produced by emotional vulnerability.
Emotional vulnerability is defined by these characteristics:
- Very high sensitivity to emotional stimuli
- Very intense response to emotional stimuli
- A slow return to emotional baseline once emotional arousal has occurred.
Emotional dysregulation is the combination of an emotional response system
that is oversensitive and overactive with an inability to modulate the resulting
strong emotions and actions associated with them.
The Role of the Invalidating Environment in Emotion Dysregulation
The crucial developmental circumstance in producing the emotion dysregulation
described above is the “invalidating environment.”
Such an environment is particularly hard for the child who begins life with
high emotional vulnerability.
A defining characteristic of an invalidating environment is the tendency to
respond erratically and inappropriately to private experiences (beliefs, thoughts,
feelings…). Invalidating environments also tend to respond in an extreme
fashion (i.e. to overreact or under react).
In addition to early failures to respond optimally, an invalidating environment
more generally emphasizes controlling emotional expressiveness, especially the
expression of negative affect. Painful experiences are trivialized and attributed
to negative traits such as lack of motivation, lack of discipline and failure
to adopt a positive attitude.
The invalidating environment contributes to emotional dysregulation by failing
to teach the child:
• To label and modulate arousal
• To tolerate distress
• To trust her own emotional responses as valid interpretations of events.
• To set realistic goals
• The communicative function of ordinary emotions
The environment shapes an emotional expression style that vacillates between
extreme inhibition and extreme disinhibition.
Modification of CBT for individuals with difficulty regulating emotions
- The emphasis on acceptance and validation of behaviour as it is in the
- Standard CBT – technology of change
- DBT emphasizes the importance of balancing the technology of change
and a technology of acceptance. Necessary for clients to be taught to
fully accept themselves and their world as they are in the moment.
- The emphasis on treating therapy interfering behaviours of both client and
- More similar to the psychodynamic emphasis on transference behaviours
and countertransference behaviours than to anything in CBT.
- The emphasis on the therapeutic relationship as essential to the treatment
- This relationship can keep a person alive and in treatment.
- Attention must be paid to factors that will enhance their attachment to
therapy and to life itself.
- The emphasis on dialectic processes
Psychosocial Skills Training
Necessary when solutions to an individual’s problems are not currently
in her behavioural repertoire.
“Skills” = ability.
The emphasis on integration of behaviours is important. Often an individual
has the component behaviours of a skill but cannot put them together coherently
The central aim of DBT is therefore, to replace ineffective, maladaptive or
nonskilled behaviours with skillful responses.
Goals of Skills Training: discuss relationship of their various characteristics
with specific skills training modules
- Interpersonal chaos – intense, unstable relationships, trouble maintaining
relationships, panic, anxiety and dread over relationships ending, frantic
attempts to avoid abandonment.
- Interpersonal effectiveness training
focuses on this – learning to deal with conflict situations, to
get what one wants and needs, and to say no to unwanted requests and demands.
It focuses specifically on doing this in a manner that maintains self-respect
and others’ liking and/or respect.
- Labile affect – moods, emotions. Extreme emotional sensitivity, ups
and downs, moodiness, intense emotional reactions, chronic depression, problems
- Emotion Regulation Training focuses
on enhancing control of emotions, even though complete emotional control
cannot be achieved. “To a certain extent we are who we are, and
emotionality is part of us. But we can get more control and perhaps can
learn to modulate some emotions to be more mellow.”
- Impulsiveness – problems with alcohol, drugs, spending, sex, fast
driving etc. Also parasuicidal behaviours.
- Distress Tolerance Training focuses
on learning to tolerate distress. Impulsive behaviour very often functions
to reduce intolerable distress.
- Confusion about self, cognitive dysregulation – problems experiencing
or identifying a self, a pervasive sense of emptiness, problems maintaining
one’s own feelings, opinions, decisions when around others. Also brief,
nonpsychotic cognitive disturbances (depersonalisation, dissociation, delusions).
- Core Mindfulness Training focuses on learning to go
within oneself and on learning how to observe oneself.
Core Mindfulness Skills
These are the first skills taught. In DBT, three primary states of mind are
- Reasonable Mind – when approaching knowledge intellectually, thinking
rationally and logically, attending to empirical facts, plans her behaviour,
focuses her attention and is “cool” in her approach to problems.
- Emotion Mind – cognitions are “hot”, reasonable, logical
thinking is difficult, facts are amplified or distorted to be congruent with
current affect and the energy of behaviour is also congruent with current
- Wise Mind – the integration of emotion mind and reasonable mind.
Adds intuitive knowing to emotional experiencing and logical analysis.
Mindfulness skills are the vehicles for balancing emotion mind and reasonable
mind to achieve wise mind.
There are 3 “what skills”
And 3 “how” skills
- Taking a nonjudgmental stance
- Focusing on one thing in the moment
- Being effective
Goal is to develop a lifestyle of participating with awareness. An assumption
of DBT is that participation without awareness is a characteristic of impulsive
and mood dependent behaviours.
Generally observing and describing one’s own behaviours are only necessary
when new behaviour is being learned, there is some sort of a problem or a change
E.g. beginning piano players pay close attention to the location of their hands
and fingers and may either count beats or name the keys that they are playing.
As skill improves such observing and describing ceases. But if a habitual mistake
is made, the player may have to resort to closer observation.
Attending to events, emotions and other behavioural responses, without necessarily
trying to terminate them when painful or prolong them when pleasant.
Learn to allow yourself to experience with awareness in the moment what is
happening rather than trying to leave a situation or terminate an emotion.
Observing an event is separate or different from the event itself. Observing
walking and walking are different, observing one’s heartbeat and the heart’s
beating are different responses.
Describing events and personal responses in words
The ability to apply verbal labels to behavioural and environmental events is
essential for both communication and self control.
Learning to describe requires that a person learn not to take thoughts and
emotions literally – as literal reflections of environmental events.
E.g. feeling afraid does not necessarily mean that a situation is threatening
to life or welfare.
Emotion Regulation is about learning how to identify emotions particularly
before they escalate, understanding the function of emotions and the factors
that increase vulnerability to emotions, learning to tolerate unpleasant emotions
and identifying ways to generate pleasant emotions. Overall this module increases
awareness of emotions, the skills needed to take care of them and live effectively
The ability to cope in a crisis (situational or emotional), how to get through
the crisis without escalating it or resorting to “problem behaviours.”
This module teaches the skills for increasing the options to effectively manage
and/or accept the difficult situations which are a normal part of life and growth.
Being effective in relationships means being able to maximise your chances
of getting your needs met in a way that maintains relationships and maintains
self-respect. An important step in this is learning to identify priorities in
interpersonal interactions and to identify and manage the barriers to interpersonal