DIALECTICAL BEHAVIOUR THERAPY
DBT understands behaviors in terms of the bio-social theory. According to this theory, our thoughts, emotions and behaviors are closely linked –– a thought triggers an emotion, which influences behavior, which leads to another emotion, then another thought in an ongoing cycle or like links in a chain, one leading to the next. Our individual experience of this cycle or chain of feeling, thought and behavior and, in particular, the emotional aspect of this cycle is influenced by our biology, as well as our social history.
Linehan (1993a) developed the bio-social theory to explain the intense and extreme emotions and related impulsive and high-risk behaviors experienced by some individuals. According to her theory, these emotions and behaviors stem from the combination of a biological vulnerability to a more extreme and fluctuating emotional experience—some people are simply wired to be more emotionally sensitive—and an environment that fails to teach an individual to modulate emotion and, through trauma or other invalidating experiences, reinforces emotional escalation.
Individual Therapy
The focus of individual therapy is on identifying and assessing problematic behaviors and their associated feelings and thoughts. Therapy is generally structured around a detailed analysis of problematic behavior, the teaching and strengthening of skills for cognitive modification and emotion modulation, learning effective behavior and addressing motivation, on-going commitment to treatment, and addressing behaviors that impede treatment.
Group Skills Training
To address emotional and behavioral skill deficits, individuals must learn new strategies for interacting with their environment. DBT skills training consists of weekly groups devoted to teaching new skills and reviewing the application of these new skills in daily life. The skills are broken down into four categories or modules (Linehan, 1993b):
The 4 Modules
- Mindfulness: These skills are fundamental to DBT and are often referred to as ‘core’. They teach how to bring awareness to everyday living. This requires focus in the present moment, a capability many people with impulsive and mood-related behaviors lack. Mindfulness is consciously bringing attention to feelings, thoughts, body sensations, behaviors and events without judgment. It is the opposite of rejecting, suppressing or avoiding current experiences.
- Distress Tolerance: In this module, skills center on accepting and coping with pain and distressing life events. These skills answer the question, ‘how do I survive this crisis.’ They focus not on changing the moment, but on accepting the current situation and finding ways to get through it without engaging in problematic behavior.
- Emotion Regulation: Emotionally sensitive individuals often are unable to modulate the painful emotions that underlie impulsive, risky behaviors. These skills include understanding current emotions, identifying obstacles to changing emotions, checking facts related to emotional reactivity, problem solving, increasing positive emotions, and changing emotions.
- Interpersonal Effectiveness: Interpersonal relationships can bring joy and happiness and cause fury or despair. This module teaches skills to get what we want and need in life, while maintaining relationships and self-respect. They include strategies for asserting your needs, saying no effectively, and coping with conflict. Skills necessary for maintaining friendships, decreasing social isolation, and ending destructive relationships are also covered.
Coaching in Crisis: In order to navigate the complex world of daily stressors, interpersonal relationships, work, obligations etc., individuals must learn to use their new skills outside of the treatment environment. Coaching in crisis is designed to allow individuals to contact treatment providers before they engage in a problematic behavior. When an individual recognizes that they are struggling they can access coaching to help initiate skillful and effective responses to their current situation.
Structuring the Environment
Principles of behavior therapy teach us that our environment has a significant influence on behavior. DBT maintains a focus on the environment in which an individual functions and actively works with individuals to create contingencies that reinforce adaptive and effective behaviors.
Couples or family treatment can be useful in structuring an environment that supports new skill use.
