What is dialectical behavior therapy (DBT)?
This week, we have the pleasure of an interview on
this very topic with Laura Schenck, M.A.. You will have the opportunity to learn what dialectical behavior therapy is and be provided with a brief overview of this modality.
Laura is currently in her third-year as a Ph.D. student, working
on her dissertation proposal, and providing psychotherapy for college students
at the University of Northern Colorado’s (UNC) counseling center. Her therapeutic approach stems from the mindfulness-based
behavioral therapies of both Acceptance and Commitment Therapy (ACT) and Dialectical
Behavior Therapy (DBT).
So without further ado, Laura, could you describe for us a bit of your background?
I was initially
interested in philosophy when I began my undergraduate studies at St. John's
College in Santa Fe, New Mexico. My academic interests gradually evolved
from an interest in why things are the way that they are to why people are
the way that they are.
I graduated from
St. Edward's University in Austin, TX, in 2007 with a B.A. in psychology.
During my time at St. Edward's University, I realized that I wanted to
begin a graduate program in psychology where I could learn the counseling
skills necessary to help people move toward their chosen life goals and dreams.
I began an M.A.
program in mental health counseling at Boston College and graduated in 2010. During
this program, I realized that I wanted to further my education within a Ph.D.
program of counseling psychology. I began my doctoral studies in the
counseling psychology program at the University of Northern Colorado (UNC) in
the fall of 2010 and have been taking coursework and seeing clients ever since.
What made you decide to
specialize in Dialectical Behavior Therapy modality?
I was drawn to
Dialectical Behavior Therapy (DBT) because of its focus on teaching individuals
the skills that enable meaningful behavioral changes in their lives. Dr.
Marsha Linehan, the founder of DBT, emphasizes that while individuals are not
responsible for "all" of their current problems, they are faced with
the task of dealing with them in the present moment nonetheless.
It does little good
to spend significant amounts of time in therapy (or in one's private life) to
dwell excessively on early life experiences with the goal of placing blame or
hoping for some form of golden insight. While insight may feel like a
relief in the moment, it requires the willingness and commitment to make
positive behavioral changes.
In this way, I
appreciate DBT's consistent emphasis on encouraging people to do different things in their
lives if they wish to get different results than they have in the past.
The idea that we can persist in repetitive unhealthy, ineffective, or
self-destructive behaviors time and time again – and expect different results –
keeps people stuck not only
in unhealthy behavioral patterns, but attached to self-defeating beliefs such
as “I’m just no good at this” or “I’m a failure.”
I have attended two
different DBT workshops (on mindfulness and emotion regulation) that were both
led by Dr. Marsha Linehan. I was consistently impressed by her enthusiasm
for and commitment to the application of DBT principles to treatment with
clients who significantly benefit from the skills of DBT's 4 modules:
mindfulness, distress tolerance, emotion regulation, and interpersonal
effectiveness.
Could you give a brief
description of what Dialectical Behavior Therapy (DBT) is?
Dialectical
Behavior Therapy (DBT) emerged from principles of Cognitive Behavioral Therapy
(CBT) as a “third wave behavioral therapy.” DBT makes use of some standard CBT
principles and techniques (e.g., identifying thoughts/behaviors and looking for
evidence that a particular thought, emotion, or behavior is “justified” – or
based in actual events/facts) to encourage distress tolerance and emotion
regulation.
DBT adds the
concept of mindfulness, as the underlying foundation behind all DBT skills.
Mindfulness is all about directing a certain type of attention to the present
moment that involves an attitude of non-judgment, openness, acceptance, and
curiosity.
Since DBT is
essentially a mindfulness-based behavioral therapy, it encourages individuals
to increase awareness of thoughts, emotions, and behaviors with greater
openness and acceptance in the present moment. For many people, the very
idea of sitting with uncomfortable experiences is difficult to imagine, much
less choosing to direct a nonjudgmental and welcoming attitude toward those
unpleasant experiences.
The key is that in
order to move through painful experiences, we must be willing to identify them,
accept their presence, refrain from judgment, and ultimately release them. This process involves learning how to
see thoughts and emotions – however painful they may be in the present moment –
as just thoughts (not “facts”) and just emotions (that are temporary states of
being).
This process does
not negate the personal experience of however painful it may be to experience
certain thoughts and emotions, but practicing mindfulness enables us to accept
the inherent pain involved in life without adding additional suffering. Pain is inevitable; suffering is
optional.
DBT adds the unique
component of focusing on creating positive changes through recognizing and
managing dialectical tensions. Many clients who benefit the
most from DBT struggle with dichotomous thinking (i.e., “black-and-white” /
“all-or-nothing” thinking) and are able to make lasting positing behavioral
changes in their lives through understanding how to allow seemingly opposing
internal states to exist together.
For example, it is
possible to feel conflicted emotions towards the same person, recognizing that
sometimes that person may be happy or kind sometimes and other times irritable or angry. The idea is to mentally hold two
opposing thoughts/emotions in one’s mind at the same time and integrate (i.e.,
synthesize or bring together) those apparent opposites to gain a greater (i.e.,
more realistic and healthy) understanding of the nuances involved in
relationships and in life.
People are neither
“all good” nor “all bad,” although many people who struggle with Borderline
Personality Disorder (BPD) have difficulty integrating opposites such as this,
which makes it challenging to create a more realistic, healthy, and nuanced
understanding of themselves, others, and the world.
DBT also includes
the idea of "wise mind," which teaches individuals how to access their deep inner
wellspring of intuitive knowing. Learning how to access wise mind
encourages people to trust themselves and their ability to choose effective
behaviors that are in their best interest.
Laura & Dr. Marsha Linehan, Founder of DBT
DBT rests upon clients
learning the critical skills of distress tolerance, mindfulness, emotion
regulation and interpersonal effectiveness. Can you explain what these
skills are and how they may be helpful?
Mindfulness is a "mental state
characterized by nonjudgmental awareness of the present moment experience,
including sensations, thoughts, bodily states, consciousness, and the
environment, while encouraging openness, curiosity, and acceptance"
(Hofmann et al., 2010, p. 169).
DBT teaches people
how to practice a wide variety of mindfulness exercises to become more
present and focused in the moment, which allows them to more effectively
tolerate uncomfortable emotions, manage those emotions, and relate more
effectively to others.
An incredible benefit of learning to practice
mindfulness is that it allows people to truly accept experiences (including unwanted thoughts and painful
emotions) instead of habitually reacting to
them with an attitude of fear and avoidance.
It is through
this present-moment awareness of internal and external experiences precisely
they are – with no attempts to change them – that people develop cognizance of
an potentially untapped inner strength capable of handling life’s difficulties
with greater poise and effectiveness than considered possible.
Mindfulness simply involves noticing and accepting the moment… right now.
Distress tolerance is "the ability to
perceive one's environment without putting demands on it to be different; to
experience one's current emotional state without attempting to change it; and to observe one's own thoughts
and action patterns without attempting to stop or control them" (Linehan,
1993, p. 147).
DBT teaches many
distress tolerance skills that help people learn how to sit with potentially
distressing emotions or thoughts without engaging in self-destructive behaviors
(e.g., self-harm, substance abuse, etc.) or unnecessarily increasing suffering. These skills include relaxation techniques,
visualization exercises, and techniques designed to increase one’s capacity to
self-soothe (i.e., provide oneself with a source of calm, comfort, and
security) in the face of distress.
Emotion regulation skills involve learning how to
effectively identify, manage, cope, and respond to internal emotional states
(e.g., anger, sadness, guilt, fear, joy, envy, etc.). DBT teaches emotion
regulation skills with the goal of increasing confidence and competence in
abilities to accurately identify emotional experiences, reduce vulnerability to
intense emotions, increase positive emotions, and change intensely distressing
emotional states through practicing "opposite action." Briefly, opposite action entails applying yourself to tasks that you do not feel like doing so as to propel yourself in a positive direction.
Interpersonal
effectiveness involves
learning to communicate with and relate to other people more effectively and
harmoniously. DBT teaches interpersonal effectiveness skills that focus
on building healthy assertiveness (i.e., behaviors that are neither passive nor
aggressive), engaging in active listening, and identifying
potential obstacles to interpersonal effectiveness that may be interfering with
positive/healthy relationships (e.g., threatening, blaming, guilt-tripping,
belittling, withdrawing, etc.)
Could you tell us about the
“wise mind” tool and how this is used?
As I began to mention
previously, "wise mind" is a concept that Dr. Marsha Linehan has incorporated
into DBT to teach people how to access the healthy and wise part of themselves
when making decisions – deep and heartfelt intuitive knowing. The idea behind wise mind is that we
all have the capacity to know what is truly in our best interest - it is just a
matter of knowing how to listen to this voice within and then take effective action based
on what wise mind is telling us.
When people learn
about wise mind in DBT, they are taught that we all operate on a continuum
between "emotion mind" and "reason mind," with wise mind
acting as the balance between the reasonable mind and emotion mind (i.e., the healthy and balanced integration of
emotion with reason).
When we are
operating solely out of emotion mind, things may feel hot, impulsive, and
hurried. There is often a tendency
to act solely based upon emotional input and processes, with little to no
integration from our more thoughtful or reasonable side. This often leads to making hasty
decisions, engaging in impulsive behaviors, or becoming intensely overwhelmed
by emotions.
On the other hand,
when operating solely out of reason mind, there is often a sense of coldness,
detachment, and disconnection that results from overly identifying with reason
and logic (at the expense of ignoring emotional input). When we choose to only utilize our
capacity for reason, problem solving, and thought, we miss out on the important
and relevant information that our emotional side holds.
The idea is that
neither emotion nor reason are necessarily “better” than the other, but rather
to become mindfully aware of information from both sides and integrate them in
a way that is most likely to bring about healthy outcomes.
Why would DBT be particularly
effective for clients with borderline personality disorder (BPD)?
DBT has
demonstrated extensive and strong empirical support in the effective treatment
of Borderline Personality Disorder (BPD), especially in significantly reducing
suicidal and self-harming behaviors.
It is particularly
effective for people struggling with BPD due to the common tendency toward
engaging in dichotomous thinking, becoming overwhelmed by intense emotions,
turning toward self-destructive/impulsive behaviors during times of distress,
and a heightened sensitivity and/or difficulty in effectively relating with
others in healthy ways.
DBT teaches the
skills necessary to address all of the primary behavioral issues associated
with BPD. (For more in-depth information on the empirical support for DBT in
the treatment of BPD, see Behavioral Tech's "What is DBT?" page.)
In light of the fact that
many people may benefit from more emotion regulation or mindfulness, do you
find yourself employing components of DBT therapy with clients who do not
suffer from borderline personality disorder (BPD)?
I absolutely
integrate mindfulness-based techniques / interventions and emotion regulation
skills with clients without a diagnosis of BPD. In fact, mindfulness based therapies such as Acceptance and
Commitment Therapy (ACT) and Mindfulness-Based Cognitive Therapy (MBCT) are
commonly and successfully used with people who do not suffer from BPD or any
other personality disorder(s).
DBT has many skills
that are incredibly helpful for people who are suffering from emotional or
relational problems that have nothing to do with a BPD diagnosis. For example, the majority of people
that I provide counseling services to and interact with outside of a counseling
setting could stand to benefit from gaining greater mindfulness in their daily
lives.
Our culture places
such great value on success, achievement, and being "busy," that many
people find themselves operating on automatic pilot a great deal of the
time. Through regular mindfulness
practices, people can learn to become more present to their lives - their
thoughts, emotions, sensations, and relationships with others.
Just as most people
could experience benefits as a result of being more mindful, many people could
also benefit from learning to regulate their emotions more effectively. Increasing emotional regulation allows
people to more accurately identify emotional states and respond to them with
greater intention.
I believe that many
clients and people not engaged in therapy receive powerful positive benefits in
their lives through learning how to respond rather than react to thoughts, emotions, sensations, and interactions with
others. I have witnessed many
clients (without a diagnosis of BPD) make incredible positive changes in their
lives as a result of learning how to practice mindfulness, tolerate distress,
regulation emotions, and relate more effectively with people in their lives.
What kind of
applications, if any, have you used to assist you with your DBT work with
clients?
Dr. Linehan is in
the process of creating and releasing a DBT skills app for the iPhone and Android
that shows great promise. The app
contains instructional videos, led by Dr. Linehan herself, going over various
DBT skills. This app should be
released sometime in 2012, and I certainly look forward to seeing how useful it
is in work with clients.
There are already a
variety of other apps out there – particularly created for use with cognitive
behavioral therapy principles – that have demonstrated success. There is certainly a movement in the
mental health field toward integrating the use of technology (e.g., through
smartphones, e-mail, Skype/video-conferencing, etc.) and research studies are
becoming more common as far as understanding how effective this use of
technology will be for clients.
While I have yet to
use or promote use of these online tools with my own clients, there are many
times when I have referred clients to my website to read an article about a
specific topic/issue they are currently dealing with in their life. It has been helpful for some clients to
read and print out mindfulness exercises from the website, so that they may
practice mindfulness skills on their own in between weekly sessions.
Finally, where would
you recommend that mental health professionals get their training in this
important modality?
The best resource for
DBT training that is endorsed by Dr. Marsha Linehan is on the training
page of the Behavioral Tech website. This is where I learned
about the two DBT workshops that I have attended, in which I had very positive
experiences.
Thanks so much, Laura, for providing us with this wonderful introduction to dialectical behavior therapy !
Feel free to follow Laura Schenck on twitter at @MindfulnessMuse or visit her Mindfulness Muse website.
Do any questions or thoughts about DBT about come to mind? Please share your comments below :)
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References:
Linehan,
M.M. (1993). Cognitive-behavioral treatment of borderline personality
disorder. New York, NY: The Guilford Press.
Hofmann,
S.G., Sawyer, A.T., Witt, A.A., & Oh, D. (2010). The effect of
mindfulness-based therapy on anxiety and depression: A meta-analytic
review. Journal of Consulting & Clinical Psychology, 78(2),
169-183.