What is Dialectical Behavior Therapy?
Dialectical Behavior Therapy (DBT) is a powerful evidenced based form of therapy that helps you to identify and work on resolving areas of conflict in your life in a somewhat different way than you might have in the past. In DBT, in a validating and supportive environment, you explore your emotions, thoughts and behavior. Many people who have problems with emotional dysregulation try avoiding any emotional feelings at all. On the other hand, they often experience their emotions in such an extreme way that it brings them a great deal of pain.
Rather than criticize people for being "too emotional" or being "too sensitive," I tell my clients that being"sensitive" is like being the Princess in The Princess and the Pea. There is nothing wrong with being sensitive. In fact, in some situations, it proves that you are royalty : )! However, like the princess in the story, your sensitivity may make it hard for you to sleep! (or to feel joy, make and maintain relationships, live the life you want to live!)
DBT teaches you to balance these extreme ways of handling emotions. By achieving balance, and acknowledging and experiencing emotions in a less extreme form, you end up being more effective in reaching your life objectives. You end up feeling better about your life. Your life opens up and becomes enjoyable as you are mindfully able to live it in the present moment.
Is your life filled with crises? Do you feel like you go from one problem to the next without a rest? DBT aims to help you prevent crises before they happen. In the nicest, least judgmental way possible, my clients often decide that they want a life with far less "drama!" They want to learn to be less "high maintenence" in relationships (again, speaking of this without criticism or judgment, but using terms such as "drama" and "high maintenance" that ring true for most people who have a really hard time regulating their emotions.) Preventing crises before they occur leads to increased emotional health and stability. In DBT, you learn the skills needed to cope and to avoid extreme emotional expression such as extreme anxiety, volatile anger and overwhelming sadness, that may be causing you a life of great distress.
One of the central dialectics examined in DBT is that of acceptance and change. Similar to the AA Serenity Prayer or the Gestalt therapy "Paradoxical Theory of Change," you learn to accept your life as it is. However, acceptance does not mean that you like the way things are. Acceptance does not mean that you are giving up or liking things that are causing you pain. The paradox is that acceptance in itself is a major change. Again, think of alcoholics who need to accept that they are alcoholics before being able to stop drinking. Similar to AA, in DBT you learn to differentiate between those things that you can change and those that you can't. For things that can not be changed, you learn the skills to accept effectively. For those things that can be changed, you learn the skills for making changes in an effective manner. Either way, you validate the feelings and the difficulty of change. If this was easy, you would have done it a very long time ago. You do all of this now in connection, collaboration and with the support of your therapist. You don't have to do this alone. We am here to help you.
The concept of mindfulness is of crucial importance in regulating emotions. Much of the agony of emotions comes from focusing on the past and worrying about the future. How many of us have spent hours and hours agonizing about things that have, in actuality, never come to pass? How many of us have spent hours being upset about things that are in the past? You may need to spend time and work on healing from things that stem from your past (that is a large part of the trauma work portion of therapy) but just thinking about and agonizing over the past does no good and leads to emotional upset in the present moment. By being mindful of the present moment, you can decrease the degree of your emotional pain, stay grounded, and appreciate life to the fullest right now, in this very moment.
DBT is a very practical approach to acceptance and change. Your success lies in learning and practicing skills every day, keeping track of progress and discovering what works for you and what does not. Don't let that intimidate you -- part of the work of therapy involves increasing motivation and problem solving about issues such as how to fit DBT homework into your day.
By working with me or one of my associates on an individual basis and/or in a group, you will have emotional support and our collaborative connection while learning the concrete strategies you need in order to deal with the painful issues in your life and make your life more livable on a day to day basis.
Dialectical Behavior Therapy was originally developed by Dr. Marsha Linehan, in 1993, to treat chronically suicidal patients with borderline personality disorder. DBT, which combines cognitive-behavioral therapy and the concepts of mindfulness and validation, is extraordinarily effective in the treatment of disorders in which the core problem is emotional dysregulation. In recent years, as its effectiveness with a wider range of populations has become apparent, DBT has been adapted to a wider range of situations. DBT is now being used in day treatment programs, private practices, prisons and hospitals. In addition to its traditional use with borderline personality disorder, DBT is now being used to treat eating disorders, bipolar disorder, complex post traumatic stress disorder, addictions, anxiety disorders, depression and any problem in which emotional regulation is a major treatment issue. DBT is now used with adolescents, teenagers, parents and families, as well as with the adult population for which it was originially developed. Adaptations of the original model now make DBT more accessible to a wider range of clients and clinicians and for the treatment of a wider range of issues.
The Major Components of DBT Skills
DBT Skills groups teach 4 different skill units developed by Dr. Marsha Linehan. More recently, a 5th module, called Middle Path and originally developed by Miller to be used in skills groups for adolescents , has been added to teach the concepts of Dialectics. DBT is a young, growing & evolving form of therapy and we strive to constantly update what we teach in our groups and in our individual therapy sessions to offer the most effective treatment possible.
The following are the four skill components included in the original DBT as developed by Dr. Linehan.
Mindfulness skills teach you to find balance between a purely rational way of thinking and a purely emotional approach to life. By balancing the two, you are able to tap into your internal wisdom.
Yes, I said your internal wisdom. You may not believe it now, but even you have internal wisdom.
It is inside of you and in DBT we will help you find it!
Mindfulness skills are divided into the What Skills and the How Skills.
What Skills include:
How Skills include:
Each DBT group session starts with a Mindfulness exercise. Practicing Mindfulness is also part of every week's homework assignment. No one ever perfects Mindfulness. Mindfulness is meant to be a practice and, no matter how many years you have been practicing, the goal is to practice some more.
Mindfulness skills teach you how to stay in the moment and be present in your life rather than letting life pass you by.
When you are distressed or are trying to figure out what to do in a difficult situation, try taking a few very slow, deep calming breaths. Then try to visualize a wise inner adviser. Sometimes it helps to put your hand on your abdomen, which is where people often find Wise Mind centered. Other people find it helpful to visualize a peaceful scene -- perhaps walking down a forest path and running into your wise inner adviser. Or you can simply ask yourself, "What Would Wise Mind say?
The answer might not be immediate. Be patient and remain open to whatever comes up for you.
The more you practice Wise Mind, the more effective it becomes. Once you get used to being in touch with your Wise Mind, your inner adviser, you will be able to tap into your own source of knowledge at any time -- it is like having your own therapist right inside of you!
2. Distress Tolerance Skills
Distress Tolerance Skills include Crisis Survival Skills and Acceptance Skills. Crisis Survival Skills do not solve crises. The goal of Crisis Survival Skills are to get you through a crisis without making things worse. Have you ever responded to a crisis situation in such a way that when the crisis was over you were left with a new problem because of what you did during the crisis? Examples might include, drinking, using drugs, overeating, quitting your job, yelling at a friend, or hurting yourself. The goal of Crisis Survival Skills is simply to get you through the crisis period without resorting to behaviors that make things worse. Again, these skills don't solve the crisis. If you can solve the problem that is what you want to do. These are the skills to get you through the period of time when you can not solve the problem. Crisis Survival Skills include various healthy ways to distract yourself, self-soothe, improve the moment and consider the pros and the cons of actions.
Acceptance Skills include Accepting Reality, Willingness (as opposed to Willfulness), Turning Your Mind and Radical Acceptance.
3. Emotional Regulation Skills
These skills help you change those emotions that you choose to change. These skills also help you get more comfortable sitting with your emotions for at a least a second and acknowledging and validating them before choosing to move away from them.
One of the expressions that many of my clients find very helpful is that of velcro and teflon minds. Velcro holds onto things while things slide off of teflon. Many people hold onto the negative experiences in their day and hardly notice, or soon forget, the positive moments. With teflon/velcro, we work on reversing that --- becoming mindful of and holding onto those things that are positive in your day and letting the negative things slide off your mind.
Think about a day in which you have had an argument with someone. How many times during the day do you replay that argument? By the end of the day have you had the argument 10 times or 100 times rather than just once? Have you resolved anything by replaying the argument over and over again or do you just feel more miserable? If you can resolve the argument by thinking about it, or if you can think of a middle ground, then by all means think about it. But, if by replaying the argument over and over again you are just getting more and more upset, then perhaps it is more effective to use skills to let go of the argument.
Now think of a positive event. What happens if you hold onto and replay that event over and over again in your head? How do you feel?
While research shows that spending a lot of time in our heads, rather than in the present moment, leads to less happiness, if you are going to be in your head, doesn't it feel better to do it by holding onto those fleeting moments of happiness in your day? Consider using your teflon/velcro skill to help yourself be mindful and to help yourself regulate your emotions.
Emotional Regulation skills include reducing your vulnerability so you are less likely to become emotionally dysregulated. There are certain things that make it harder to stay in control emotionally. These include being sick, not getting enough sleep or exercise, and using mind altering drugs. Certain hormonal states can also make people more vulnerable to emotional dysregulation. So can being in pain. You can focus on preventing some of these things that make you more vulnerable. Others can't be avoided, but it still helps to be aware of them and know when you are more vulnerable so that you can more closely monitor your behavior.
There are also things that make us less vulnerable and, in fact, help build our emotional resiliency. We can build mastery experiences and positive experiences. You might think of this as being similar to putting away money for a rainy day. You want to fill up your emotional bank account with positive experiences so you have them to fall back on during harder times.
Most of my clients tell me that Opposite Action is one of their favorite skills. In DBT, we say that Emotions Love Themselves. ln fact, each emotion has with it an action urge and, if you follow the action urge that goes with the emotion, the emotion will grow...which is exactly what that emotion wants to do. Now, the emotion does not have bad intentions. The emotion thinks that it is keeping you safe, but in reality it is keeping you from living the life you want to live. So, that is something we have to change.
Let me give you an example to help clarify what I mean. The action urge that goes with depression is to do nothing; to pull up the covers and stay in bed. If you follow this urge and stay in bed, you will become even more depressed. Opposite Action means that you do the opposite of the urge. In other words, you get out of bed. However, you can't just get out of bed and then go lie on your coach. When you do opposite action, you have to really do 100% opposite action. So, what is the urge when you are afraid? The action urge that goes with fear is to avoid whatever it is that is scaring you. Have you ever avoided something because you were scared? Most people have. What happens? Right -- you get more scared. So, the opposite of avoidance is first checking to see if there is actual & immediate life threatening danger associated with what you are afraid to do. If not, if the action is safe, then opposite action means that you approach rather than avoid what you are scared of. This is not usually an easy skill to master and it often takes a lot of coaching. Your group leader will walk you through it and the other group members will support you and help you come up with ideas and stay motivated to take these important steps. Once you master this skill, you too might find that it becomes one of your favorites.
4. Interpersonal Effectiveness Skills
These skills teach effective strategies for obtaining, changing, and maintaining relationships, maintaining self respect and coping with interpersonal situations.
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Serving the Metro Washington, D.C. area.
Located in Bethesda, Montgomery County, MD