Dialectical Behaviour Therapy

What is Dialectical Behaviour Therapy (DBT)?

A dialectic is:

the existence or action of opposing social forces or concepts

DBT was developed to support individuals who are often faced with dialectics in their life – for example, they love and dislike someone at the same time; they feel they need people in their lives but also have a strong sense of independence. In DBT the core dialectic focuses on the treatment philosophy – it is about finding a way to develop both change (in your thinking, feelings and behaviour) and acceptance of who you are.

DBT was first developed by Marsha Linehan in 1980. She was working with individuals with high levels of self-harm and suicidality, who were often given the diagnosis of Borderline Personality Disorder (BPD – also known as Emotionally Unstable Personality Disorder). She noticed that regular cognitive and behavioural strategies did not work with such individuals.

It is hard to be happy without a life worth living.  This is a fundamental tenet of DBT 

Marsha Linehan

Bio Social Model

The Bio Social model was developed to help explain the development of personality problems. The theory suggests that BPD is primarily a disorder of the emotion regulation system. Emotion dysregulation is considered to develop due to two factors:

EMOTIONAL VULNERABILITY (BIO)

• This focuses on our biological characteristics – what we are born with.
• Firstly, a person may be emotionally vulnerable and sensitive. They will feel emotions more often than others, and these will have a greater intensity. It can feel like these emotions come from nowhere, they reach high levels quickly but then take much longer to reduce again.
• An individual also has higher levels of impulsivity. This means that they can find it hard to stop themselves from acting quickly with little thought. Such behaviour may get them into trouble, but can also feel like they have no control over it.
• They may also find it hard to set and achieve goals, because their emotions gets in the way.
• There is no single cause for these biological predispositions for BPD. For some, it could be hereditary but for others, there could be other acquired causes, e.g. during pre-natal or post-natal development.

ENVIRONMENTAL EXPERIENCES (SOCIAL)

• The type of early environment that contributes to BPD is called “the invalidating environment”. This environment is typically the family environment but isn’t necessarily one in which a child is abused or neglected. Even the most well-intentioned families can be invalidating.
• An invalidating environment is one in which a child’s needs are not met with understanding and compassion but erratic, inappropriate and extreme responses. Their feelings are not validated, but disregarded, punished or trivialised, and not viewed as valid responses to events. This tells the child that their thoughts or feelings are just plain wrong.
• For example, if a child expresses upset, the family does not pay attention or tells her she’s making a big deal about it, they invalidate her inner experience.
• Those who grow up in an invalidating environment learn to believe that their actions, thoughts, and feelings don’t matter. This can hinder their ability to recognise their own emotions and cause them to distrust their emotions. It also does not teach them to effectively regulate their emotions, problem-solve or form realistic goals for the future. The child learns that extreme emotional displays are necessary to get help, so moves between holding things in to erupting. They may later turn to substance abuse or self-harm as a way to better cope with and control their emotions.

Radical acceptance is about accepting life on life’s terms and not resisting what you cannot or choose not to change

Marsha Linehan

What does DBT therapy involve?

DBT developed to include a focus on four main areas, and these are addressed within skills groups:

• Mindfulness: A focus on developing your ‘wise mind’ through a range of mindfulness exercises; focus on the here and now rather than allowing yourself to get stuck in the past, or worrying about the future.
• Emotional Regulation: This module helps you to understand why we have emotions. It then looks at skills to be able to manage when you feel these, but also strategies to reduce the likelihood of them happening.
• Distress Tolerance: This focuses on skills to help you manage when you are in a crisis – your emotions feel overwhelming and as if nothing will help. At such times, trying to use cognitive techniques is unlikely to work, so these skills are simple, behavioural strategies to help you manage. It also teaches the idea of radical acceptance, for when we can’t change an upsetting situation or circumstance.
• Interpersonal Effectiveness: This looks at developing skills in being able to communicate with others effectively – by learning to put your point across in an assertive, but non harmful way.

Full DBT therapy involves a number of components and should be completed by a team of therapists. These are:

• Weekly individual sessions which focus on the individual discussing any life threatening, therapy interfering or daily living interfering problems. The individual is asked to identify specific problem behaviours which they then record on a weekly diary sheet. The individual session involves completing a ‘Behavioural Chain Analysis’ to explore the most problematic behaviour, and then a focus on agreeing on and practising skills that could have been used to manage this.
• Group skills sessions focus on the four modules above. These are an opportunity to learn specific skills and start to apply them to yourself, whilst also learning from other people’s experiences.
• Access to ‘emergency coaching’ outside of sessions, if you find yourself in a crisis. These are 15-minute telephone conversations with a focus on agreeing on strategies to manage.
• The therapy team also have weekly consultation (supervision) sessions to discuss the clients that they are working with and gain support.

There is a large evidence base for DBT as an effective treatment for BPD. It is mentioned in the NICE guidelines for Borderline Personality Disorder as an evidence-based therapy which works.

Individual Therapy:

I am unable to offer full DBT to clients at the moment. However, I am able to offer a CBT approach which includes DBT skills, which includes aspects of the individual and group sessions above. This would involve an assessment of your needs and an individualised plan developed with respect to which areas may be most beneficial to you.

At present I am unable to offer emergency coaching outside of the session, however, I would always develop a keep safe plan with individuals which includes an agreement of how to access support in a crisis. I am unable to work with individuals who are regularly self harming or are suicidal. In these cases, a team approach is required and I recommend that you contact your local NHS mental health service.

Interested in completing DBT informed work? Please contact me

If you would like to know more about DBT, below are some Youtube videos you may find interesting:

Introduction to DBT

Radical Acceptance with Marsha Linehan

An introduction to Mindfulness in DBT

There are a number of Apps that also offer an introduction to DBT (I would recommend these being used alongside therapy):

DBT Coach

Calm Harm