The Down & Dirty of DBT (Dialectical Behavior Therapy)

This past week, I had the opportunity to attend a 2 hour DBT 101 training, free through my employer. 

As a Child Protective Services social worker, I have seen the benefits of DBT with various clients over the years and knew it had some very valuable tools, but I had never taken the time to learn much about it.  So I thought this was my opportunity. 

Dialectical Behavior Therapy (DBT) centers around the fact that two opposing facts can be true at the same time.  For example - "I am tough, but I'm also gentle." or my favorite, "I'm doing the best I can, and I can do better."  DBT is an evidence based practice that stems from Cognitive Behavioral Therapy (CBT) and was originally created to treat Borderline Personality Disorder.

I learned about the Bio-Social Theory around DBT.  Bio - there is a biological vulnerability to emotions and Social - an invalidating environment that communicates that what you're feeling, thinking or doing doesn't make sense.  This create multiple problems - chronic emotional dysregulation.

There are 4 options for dealing with any problem - (1) solve the problem, (2) tolerate the problem, (3) feel better about the problem, and (4) stay miserable or make things worse.  The thing is, we can't always solve the problems in our lives.  Some things our outside of our control, so we may have to choose one of the other options.  And, ideally, we don't choose #4, because, well, who wants to stay miserable?  However, for some people, that seems like the only way out...to be miserable and become the victim.  And that's where DBT can be most helpful.

There are 5 modules of DBT Skills Training: 

1) Mindfulness - the quality of state of being conscious or aware of something; a mental state achieved by focusing one's awareness on the present moment, while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations used as a therapeutic technique.

There are 3 states of mind - the Emotional Mind, the Reasonable Mind, and the Wise Mind.  The Wise Mind is where we're seeking to make our decisions from.  The Wise Mind is where the Emotional Mind and the Reasonable Mind overlap.

Mindfulness skills are made up of "What" skills and "How" skills.  The "what" skills are what we observe, what we describe, and what we participate in.  The "how" skills are noticing our judgments, staying focused, and doing what works.

2)  Distress Tolerance - a person's ability to manage actual or perceived emotional distress; it also involves being able to make it through an emotional incident without making it worse.  

There are several tools within this skill:

ACCEPTS (Activities, Comparisons, Contributions, Emotions, Pushing Away, Thoughts, Sensations).  This is used to help a client be distracted from the stressful thought or situation and helps to regulate their emotions.

Self Soothe with the Six Senses - Sight, Hearing, Smell, Taste, Touch, and Movement.                 We typically only hear about 5 senses, but the sense of movement, for self soothing or crises management, can be very important.  This involves thinking about and recognizing all the things around you that you can see, hear, smell, taste, and touch and becoming hyper-aware of each of them.  The sense of movement allows you to move around within your environment to more fully experience the other senses.

TIPP - Temperature, Intense Exercise, Paced Breathing, and Progressive Muscle Relaxation.  This alters your body chemistry to reduce extremes of the Emotional Mind.  Simply put, doing these things allows or requires your mind and body to focus on the activity, instead of the thing that's causing extreme stress or anxiety.

Pros & Cons - This skills taps into the Reasonable Mind, to think logically about the thought that brings us distress and to dissect it in such a way that the power of it is decreased.

3)  Emotion Regulation - the ability to respond to the ongoing demands of experience with the range of emotions in a manner that is socially tolerable and sufficiently flexible to permit spontaneous reactions as well as the ability to delay spontaneous reactions as needed.

The goals of emotion regulation are to understand the emotions that you experience, reduce the emotional vulnerability and stop unwanted emotions from starting in the first place, decrease the frequency of unwanted emotions, and to decrease emotional suffering, stop or reduce unwanted emotions once they've started.

Some skills in this area are:

ABC - Accumulate Positive Experience, Build Mastery, and Cope Ahead.  This allows us to gather positive experiences, even in the face of difficulties, learn how to master our emotions using those accumulated experiences, and the use that to cope with similar situations in the future.  Practice makes perfect!            

PLEASE - Treat PHYSICAL illness, balance EATING, AVOID mood-altering drugs, balance SLEEP, and get EXERCISE.  

Problem Solving - (1) Figure out and describe the problem, (2) check the facts to be sure you have the right problem situation, (3) identify your goal, (4) brainstorm lots of solutions, (5) choose a solution that fits the goal and is likely to work, (6) put the solution into action, (7) evaluate the results of using the solution.  Start over with #5 if the chosen solution didn't work effectively.

4)  Interpersonal Effectiveness - the skills which help us to: attend to relationships, balance priorities vs. demands, balance the "wants" and the "shoulds", and build a sense of mastery and self-respect.

Several skills in this area are:

GIVE - (be) GENTLE-be kind and respectful, don't attack, and be aware of your tone of voice, (act) INTERESTED-listen and act interested to what the other person is saying, don't interrupt, talk over, or make faces, and maintain good eye contact, VALIDATE-show that you understand the other person's feelings or opinions, and be non-judgemental out loud, and (use an) EASY MANNER-smile, use homor, and use non-threatening body language.

DEAR MAN - DESCRIBE the situation, EXPRESS using "I" statements and emotion words and avoid "shoulds", ASSERT by asking directly and being specific, and REWARD by explaining the benefits to the other person by granting your request and by expressing gratitude.  Be MINDFUL by staying focused on the goal, and returning to your request repeatedly if necessary, APPEAR confident by making eye contact, noticing your posture, and considering your tone of voice, and NEGOTIATE by being willing to "give" to "get" and brainstorming ways the other person could grant your request.

FAST - (be) FAIR to yourself and others, (no) APOLOGIES, STICK to your values by not selling out and being clear about what you believe, and (be) TRUTHFUL by no lying or acting helpless when you aren't.

THINK - THINK about it from the other person's perspective, HAVE empathy, INTERPRETATIONS, NOTICE other ways the person is contributing, and KINDNESS.

5) Walking the Middle Path - is about balance.  It's an alternative to black and white thinking and polarization, both of which are particularly common among people with emotion regulation issues, but which everyone is prone to occasionally.  

This relies on dialectics quite a bit and encourages us to confront our thinking mistakes.  It also uses validation and the recovery from invalidation as a way to stay balanced, and takes all of it into consideration to develop strategies to change our behavior.

So there you have the down and dirty, over-simplified explanation of DBT, as I learned from Amber Gonzalez, LMFT through Seneca SF Connections in San Francisco.  

I've never been formally trained in DBT, yet my biggest take away from this training was a realization that I already use MANY of these skills in my therapeutic work with clients.  My mind must already work in a DBT kind of way and these skills comes naturally.  However, I did appreciate learning some new skills and diving deeper in to some of the skills I already use. 

DBT can be adapted and used in many ways with clients and in co-worker or relationship interactions.  Our lives are filled with dialectics, so we ought to learn how to embrace them and use them to our advantage.

I'm happy to have been able to share, briefly, with you about the basics of DBT.  And I look forward to sharing my thoughts with you each week.

Brittanie D. Mills, LMFT

Website:  www.brittaniedmillslmft.com

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