Dialectical Behaviour Therapy in Practice

There are four primary modes of treatment, or elements, in Dialectical Behaviour Therapy:

  1. Therapist consultation groups
  2. Individual therapy
  3. Telephone contact/crisis coaching
  4. Group skills training (Mind, 2013).

Not all DBT programs carry all four modes of treatment. When they do, the various modes can be described as follows.

Therapist consultation groups

An essential aspect of the therapy is that therapists, who usually work in teams rather than independently, receive DBT from each other. Working with people who have suicidal ideas and are self-harming can be very stressful, so the members of the group undertake to keep each other in DBT mode: being dialectical with one another and avoiding pejorative descriptions of either client or therapist behaviour.

The weekly sessions are a form of group supervision, in which therapists express feelings and concerns about the therapy they are giving, and solicit advice and different ideas for treatment. Members strive to respect one another’s limits and to treat one another as well as they treat their clients (Psych Central, 2007a; Mind, 2013).

Individual therapy

A client’s individual therapist is the primary therapist and the main work of therapy is carried out in weekly, individual sessions which are (approximately) one-hour-long. BPD clients present multiple problems, which can pose challenges for the therapist in deciding what to focus on and when. DBT therapists generally regard the therapy as having a pre-treatment stage and three therapeutic stages.

Each stage has clear goals and is structured in terms of hierarchies of targets at each stage. The goal behaviours of each stage are brought under control before moving on to the next phase. Every session has a goal of helping the client to think more dialectically; it is here that the client’s diary cards (see below) are reviewed and worked through, along with discussion of self-injurious behaviours and obstacles to acting skilfully (Wikipedia, 2013; Mind, 2013).

The pre-treatment stage does the assessment, contracts for commitment, and orients the client to the therapy. Stage 1 focuses on suicidal behaviours, therapy-interfering behaviours, and behaviours that interfere with the quality of life. It is here that clients must develop the skills necessary to resolve these problems. It is a particular characteristic of DBT that so much importance is given to halting so-called “therapy-interfering” behaviours; this reflects the difficulty of working with Borderline clients.

Included in this category are any behaviours by either the therapist or the client which get in the way of proper conduct of the therapy and risk the client not getting what she needs to get better. Some examples are failure to keep to contracted agreements, failure to attend sessions regularly, and any behaviours that overstep the therapist’s limits. Similarly, behaviour deemed to be interfering with the quality of life are things such as substance abuse, sexual promiscuity, high-risk behaviour, or anything agreed between therapist and client in negotiation as belonging in this category. Finally, one of the treatment strategies is to ask clients to complete diary cards, onto which they record emotions and actions. Failure to bring completed diary cards also constitutes a therapy-interfering behaviour.

Stage 2 deals with post-traumatic stress-related problems. Specifically, the PTSD problems related to childhood sexual abuse are not dealt with directly until Stage 1 behaviours have been mastered. Stage 3 focuses on self-esteem and individual treatment goals (Psych Central, 2007a; Mind, 2013).

Telephone contact/crisis coaching

One of the more contentious issues related to being a DBT therapist is the requirement to provide telephone contact or crisis coaching, including out-of-hours contact. The therapist, while needing to agree to provide the contact, may nevertheless set limits on it, and in any case the purposes of such contact are clearly defined. It is not for the purpose of doing psychotherapy. Rather, the client may telephone her individual therapist in the following situations:

  1. When she needs help dealing with a crisis situation (such as feeling suicidal or having an urge to self-harm);
  2. When she is trying to use DBT skills but wants some advice on how to do it;
  3. When she wants to repair her relationship with the therapist, and does not want to wait until the next session in order to do it.

In order to avoid reinforcing self-harm, calls are not acceptable after the client has injured herself and – after ensuring her immediate safety – calls are not allowed for a further 24 hours (Psych Central, 2007a).

Group skills training

Group skills training sessions, which are not group psychotherapy sessions, allow DBT therapists to teach skills that can help people deal with life situations more effectively. Ideally, these skills are conducted by a different therapist than the “primary therapist” with whom the BPD client is having individual sessions. The skills taught are comprised of four modules or clusters of skills which are recognised as being particularly relevant to BPD clients.

Mindfulness skills

Derived from certain techniques of Buddhist and other Eastern spiritual practices, mindfulness skills are psychological and behavioural versions of meditation practices which do not involve any religious allegiance to apply them. Essentially they are techniques to enable the practitioner (the BPD client) to become more aware of the contents of experience, and to develop the ability to stay with that experience in the present moment.

In DBT, there are held to be three primary states of mind:

  1. Reasonable mind, which a person is in when she approaches information and knowledge intellectually;
  2. Emotion mind, when her thinking and behaviour are controlled primarily by her current emotional state; and
  3. Wise mind, when a person has integrated emotional experience and logical analysis and added in intuitive knowledge (Linehan, 1993, in ASCA, 2008; Psych Central, 2007a; Mind, 2013).

The chart below helps clients to understand the dialectical resolution between Reasonable Mind and Emotion Mind which results in the integrated Wise Mind:

Emotion MindWise Mind
(Integrates Emotion Mind and Reasonable Mind)
Reasonable Mind
Thinking and behaviour controlled by emotional stateAdds intuitive knowing to emotional distress and logical analysisIntellectual, scientific
Thoughts are unhelpful and distressingThe calm that follows a stormLogical and rational thinking
Difficult to think logically and rationallySees or knows something directly and clearlyFactual thinking, based on evidence
Facts are distorted to fit with current distressGrasps the bigger picture, rather than just partsAble to plan how to respond
OpinionsEnsures needs of both Emotion Mind and Reasonable Mind are met. Reasonable Mind is right, but Emotion Mind needs to be soothedFocuses attention
Strong emotions drive strong behaviourWhat are the most appropriate and effective skills that I could use for this situation?Cool in approaching problems
What I want to doWhat I should do

(Vivyan, 2010)

Interpersonal effectiveness skills

The response patterns taught in DBT skills training focus on effective ways of achieving one’s objectives with other people; they are similar to many assertiveness and interpersonal problem-solving classes. These include acquiring effective strategies for coping with conflict, asking to have one’s needs met, and saying no.

Mental health experts writing about BPD often comment how the BPD-diagnosed individual will possess a general knowledge of the skill sets; the problem comes when she tries to apply it. She may be able to name all the steps in a behaviour sequence for someone else with a problem, but will completely incapable of generating the same behaviour sequence for her own similar problem.

Thus the module focuses on situations where the objective is to change something (that is: request that someone do something) or to resist change happening (that is: say no). The skills taught are designed to maximise the client’s chances of getting her needs met without damaging either her self-esteem or her relationship with another person (ASCA, 2008).

Emotional regulation

BPD-diagnosed clients and those who are suicidal tend to be emotionally intense and unstable. Mood can range from depressed or anxious to angry or intensely frustrated, so an important aspect of the healing is to learn to regulate their emotions in order to change from distressing emotional states. DBT skills for emotional modulation include:

  • Identifying and labelling 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 (below) (Linehan, 1993, in ASCA, 2008).

Distress tolerance techniques

In teaching participants how to deal with crises in a more effective way, without having to resort to self-harm or other problematic behaviours, distress tolerance skills have the objective of showing people how to bear pain and distress skilfully. It should be noted that many current approaches to mental health treatment focus on changing distressing events and situations rather than on accepting them. Psychodynamic, psychoanalytic, gestalt, and narrative therapies, conversely, have equipped clients working in them to accept and tolerate distress, often through finding meaning in it.

Distress tolerance skills have to do with the ability to accept both oneself and the situation without judgment or evaluation. This does not mean that the person with BPD must approve of a given situation; acceptance of reality does not equate to approval of reality. In some instances the client is led into another dialectical stance: accepting reality as it is in the moment, while (possibly) not approving and thus deciding to work in future to change things. So the BPD client might be hugely distressed that she has alienated a significant relationship with an over-the-top emotional reaction.

DBT would take the stance that she should hold a point of tension with the two apparent irreconcilable facts: (1) she has responsibility for having created a bad situation relationally and must accept this reality (and herself) and (2) she doesn’t have to approve of how she or the other person reacted; she can work in future to respond in ways which do not create ill will between herself and another. She may be able to bear the distress of the moment better if she can make meaning of it: i.e., “Well, this event has shown me that things don’t work out well when I don’t modulate myself. I’m an ok person even if I lost my temper this time, but I can see now where I have room for improvement.” Four crisis-survival techniques for distress tolerance can help her get through the moment: distraction, self-soothing, improving the moment, and thinking of pros and cons (Linehan, 1993, in ASCA, 2008; Psych Central, 2007a; Mind, 2013).

These four elements, or modes, comprise the “architecture” for DBT treatment. Within this last mode, group skills training, reside a rich set of techniques and strategies to improve the DBT client’s skills.

If you are interested in knowing more about these, we advise you to purchase Linehan’s handbook: Skills training manual for treating Borderline Personality Disorder (Guilford Publications, 1993), or go online to http://bit.ly/1mGNFyt and download the Dialectical Behavior Therapy Skills Handbook put out by Fulton State Hospital (2004, adapted from Linehan’s work). Here we offer you a sample exercise for each of the four clusters of skills.

Sample DBT group skills exercises

Core Mindfulness skills

DBT group skills trainers divide core mindfulness skills into two groups: the “What” skills and the “How” skills. Program participants are taught to “take hold of your mind” and to practice using all of the skills at the same time.

The ‘What’ skills: Observe, Describe, Participate

Observe

  • Be curious about what you feel.
  • Just notice how you feel, without trying to make feelings stronger, or weaker, go away, or last longer.
  • See how long your feeling lasts, and if it changes.
  • Notice how feelings flow in and out of your body like waves.
  • What comes through your senses? Touch, smell, sight, sound, taste.
  • Be like a non-stick pan, letting things slide off of your body and your emotions.

Describe

  • Use words to describe your experience.
  • Use “fact” words, call a thought “just a thought”, call a feeling “just a feeling”.
  • Use words that everyone would agree with.
  • Don’t paint a colourful picture with words, or magnify a situation with words. Try to avoid emotional words.
  • Try to let go of your emotions about being “right” or about someone else being “wrong” while searching for words to describe.

Participate

  • Get “lost” in an activity.
  • Let go of your sense of time while you are doing something.
  • Allow yourself to be natural in the situation.
  • Practice your skills until they become a part of you (Fulton State Hospital, 2004, pp 15-16).

The ‘How’ skills: Non-judgmental Stance, One-Mindfully in the Moment, Effectively

Non-Judgmental Stance

  • See, but don’t evaluate. Take a non-judgmental stance. Just the facts.
  • Focus on the “what”, not the “good” or “bad”, the “terrible”, the “should” or “should not”.
  • Unglue your opinions from the facts, from the “who, what, when, and where.”
  • Accept each moment, each event as a blanket spread out on the lawn accepts both the rain and the sun, each leaf that falls upon it.
  • Acknowledge the helpful, the wholesome, but don’t judge it. Acknowledge the harmful, the unwholesome, but don’t judge it.
  • When you find yourself judging, don’t judge your judging.

One-Mindfully in the Moment

  • Do one thing at a time. When you are eating, eat. When you are walking, walk. When you are working, work. When you are in a group, or a conversation, focus your attention on the very moment you are in with the other person. Do each thing with all of your attention.
  • If other actions, thoughts, or strong feelings distract you, let go of distractions and go back to what you are doing—again, and again, and again.
  • Concentrate your mind. If you find you are doing two things at once, stop and go back to one thing at a time.

Effectively

  • Focus on what works. Do what needs to be done in each situation in order to meet your larger goals. Stay away from thoughts of “right”, “wrong”, “should”, “should not”, “fair” and “unfair”.
  • Play by the rules. Act as skilfully as you can, meeting the needs of the situation you are in, not the situation you wish you were in.
  • Let go of vengeance, useless anger, and righteousness that hurts you and doesn’t work. (Fulton State Hospital, 2004, pp 15-16)

Interpersonal skills: Getting what you want with “DEARMAN”

To help BPD clients learn how to get their needs met relationally — including by being willing to help others meet their needs – the use of the “DEARMAN” acronym is promoted as a guideline for objectives effectiveness. The letters stand for:

Describe
Express
Assert
Reinforce
(stay) Mindful
Appear confident
Negotiate

Describe the current situation (if necessary). Tell the person exactly what you are reacting to. Stick to the facts.

  • Express your feelings and opinions about the situation. Assume that your feelings and opinions are not self-evident. Give a brief rationale. Use phrases such as “I want”, “I don’t want,” instead of “I need,” “you should,” or “I can’t.”
  • Assert yourself by asking for what you want or saying no clearly. Assume that others will not figure it out or do what you want unless you ask. Assume that others cannot read your mind. Don’t expect others to know how hard it is for you to ask directly for what you want.
  • Reinforce or reward the person ahead of time by explaining the consequences. Tell the person the positive effects of getting what you want or need. Tell him or her (if necessary) the negative effects of not getting it. Help the person feel good ahead of time for doing or accepting what you want. Reward him or her afterwards.
  • (stay) Mindful. Keep your focus on your objectives. Maintain your position. Don’t be distracted.
    • “Broken Record” can be used. Keep asking, saying no, or expressing your opinion over and over and over. Keep your voice calm and even while doing this.
    • Ignore. If another person attacks, threatens, or tries to change the subject, ignore the threats, comments, or attempts to divert you. Don’t respond to attacks. Ignore distractions. Just keep making your point.
  • Appear Confident. Appear effective and competent. Use a confident voice tone and physical manner; make good eye contact. No stammering, whispering, staring at the floor, retreating, saying “I’m not sure,” etc.
  • Negotiate. Be willing to give to get. Offer and ask for alternative solutions to the problem. Reduce your request. Maintain no, but offer to do something else or to solve the problem another way. Focus on what will work. You can also try to:
    • Turn the tables. Turn the problem over to the other person. Ask for alternative solutions: “What do you think we should do?” “I’m not able to say yes, and you seem to really want me to. What can we do here?” “How can we solve this problem?” Think about what you are willing to “settle for” or “give up” in order to gain what you want in the situation (Fulton State Hospital, 2004, pp 21-22).

Emotional regulation skills: Letting go of emotional suffering through mindfulness

Because BPD clients often have such intense emotions, part of learning to cope is learning how to regulate emotions. Part of that is learning to identify and disidentify from emotions at will, thus allowing the BPD to let go of unhelpful emotions. The following guidelines suggest a mindfulness-based means of becoming aware of a current emotion, in order to let go of the emotional suffering that has come with it.

Observe your emotion

  • Note its presence.
  • Step back.
  • Get unstuck from the emotion.

Experience your emotion fully

  • Feel it as a wave, coming and going.
  • Try not to block emotion.
  • Try not to push away the emotion.
  • Don’t try to keep the emotion around.
  • Don’t try to increase the emotion.
  • Just be a witness to your emotion.

Remember: You are not your emotion

  • Do not act on the sensation of urgency.
  • Remember when you have felt different.
  • Describe your emotion by saying “I have the feeling of _______”, rather than, “I am ____.”
  • Notice other feelings that you have at the same time you feel the strong emotion.

Practice respecting, loving your emotion

  • Don’t judge your emotion.
  • Practice willingness with your emotion.
  • Radically accept your emotion (Fulton State Hospital, 2004, p 57).

Distress tolerance skills: Self-soothing through “Improve the Moment” and “ACCEPTS”

Distress tolerance skills constitute a natural development from DBT mindfulness skills. The goal is to become capable of calmly recognising negative situations and their impact, rather than becoming overwhelmed or hiding from them. As part of learning to accept situations they would otherwise have found unpalatable, BPD clients in DBT training programs are taught how to soothe and distract themselves. This allows them to make wise decisions about whether and how to take action, rather than falling into the intense, often destructive emotional reactions that are part of BPD. One technique to do this is called “Improve the Moment”, and the acronym “IMPROVE” tells how to do this:

  • Imagery: Imagine a very relaxing scene. Imagine a secret room within yourself, seeing how it is decorated. Go into the room whenever you feel very threatened. Close the door on anything that can hurt you. Imagine everything going well. Imagine coping well. Make up a fantasy world that is calming and beautiful and let your mind go with it. Imagine hurtful emotions draining out of you like water out of a pipe.
  • Meaning: Find or create some purpose, meaning, or value in the pain. Remember, listen to, or read about spiritual values. Focus on whatever positive aspects of a painful situation you can find. Repeat them over and over in your mind. Make lemonade out of lemons.
  • Prayer: Open your heart to a supreme being, greater wisdom, God, your own wise mind. Ask for strength to bear the pain in this moment. Turn things over to God or a higher being.
  • Relaxation: Try muscle relaxation by tensing and relaxing each large muscle group, starting with your hands and arms, going to the top of your head, and then working down; listen to a relaxation tape; exercise hard; take a hot bath or sit in a hot tub; drink hot milk; massage your neck and scalp, your calves and feet. Get in a tub filled with very cold or hot water and stay in it until the water is tepid. Breathe deeply; half-smile; change facial expression.
  • One thing in the moment: Focus your entire attention on just what you are doing right now. Keep yourself in the very moment you are in; put your mind in the present. Focus your entire attention on physical sensations that accompany non-mental tasks (e.g. walking, washing, doing dishes, cleaning, fixing). Be aware of how your body moves during each task. Do awareness exercises.
  • Vacation: Give yourself a brief vacation. Get into bed and pull the covers up over your head for 20 minutes. Give yourself a special treat to eat or drink and read a magazine for an hour. Take an hour breather from hard work that must be done.
  • Encouragement: Cheerlead yourself. Repeat over and over; “I CAN stand it,” “It won’t last forever,” “I will make it out of this,” “I’m doing the best I can do.” (Fulton State Hospital, 2004, p 63)

The second technique, “ACCEPTS”, is also an acronym. This is a skill used to distract oneself temporarily from unpleasant emotions:

  • Activities: Use positive activities that you enjoy.
  • Contribute: Help out others or your community.
  • Comparison: Compare yourself either to people that are less fortunate or to how you used to be when you were in a worse state.
  • Emotions (other): Cause yourself to feel something different by provoking your sense of humour or happiness with corresponding activities.
  • Push away: Put the situation on the back burner for a while. Put something else temporarily first in your mind.
  • Thoughts (other): Force your mind to think about something else.
  • Sensations: (other): Do something that has an intense feeling other than what you are feeling, like a cold shower or a spicy candy (Dietz, L., 2003, in Wikipedia, 2013).

This article was adapted from the Mental Health Academy CPD course “Dialectical Behaviour Therapy”. For more information about MHA, visit www.mentalhealthacademy.com.au.

References

  • Adults Surviving Child Abuse. (2008). Dialectical Behaviour Therapy (DBT). ASCA. Retrieved on 5 November, 2013, from: hyperlink.
  • Linehan, M. (1993). Skills training manual for treating Borderline Personality Disorder. United States: Guilford Publications.
  • Fulton State Hospital. (2004). Dialectical Behavior Therapy: Skills handbook. Fulton State Hospital. Retrieved on 19 November, 2013, from: hyperlink.
  • Mind (2013). Dialectical behaviour therapy. Mind. Retrieved on 5 November, 2013, from: hyperlink.
  • Psych Central. (2007a). Dialectical Behavior Therapy in the treatment of Borderline Personality Disorder. PsychCentral. Retrieved on 5 November, 2013, from: hyperlink.
  • Wikipedia. (2013). Dialectical behavior therapy. Wikipedia. Wikimedia Foundation, Inc. Retrieved on 5 November, 2013, from: hyperlink.