Dialectical behavior therapy (DBT): skills for overcoming depression & emotional dysregulation

Dialectical Behavior Therapy (DBT)

• DBT stands for Dialectical Behavior Therapy
• A form of talk therapy inspired by Cognitive Behavioral Therapy (CBT)
• Designed for individuals with complex mental health problems 
  • Originally for suicidal or self-​​harming individuals
  • May meet criteria for Borderline Personality Disorder
• More structured and guided than traditional talk therapy
• Evidence-​​based approach

Cognitive Behavioral Therapy (CBT)

• Present-​​focused therapy
• Works with thoughts and behaviors contributing to current problems
• Developed by Aaron Beck in the 1960s
• Effective for anxiety disorders and depression 
  • Changes thoughts and behaviors through exposure and problem-solving
• Randomized clinical trials show positive results compared to standard care

Origin of DBT

• Marcia Linehan, founder of DBT
• Originally applied standard CBT to chronically suicidal individuals
• Recognized limitations of CBT for certain patients and problems
• Developed DBT to address these limitations and provide more comprehensive care
  Marcia Linehan and Borderline Personality Disorder (BPD)
• Marcia Linehan diagnosed with schizophrenia as a young girl 
  • Treated with electroconvulsive therapy and strong antipsychotic meds
  • Later, likely misdiagnosed; possibly had Borderline Personality Disorder (BPD)
• BPD defined by nine criteria in the DSM 
  • Must endorse five of the nine to have the condition
  • Core domain: emotion dysregulation 
    • Intense emotions, difficulty controlling emotions, rapid emotional changes
  • Other domains of dysregulation stem from emotion dysregulation 
    • Behavior dysregulation: impulsivity, substance use, reckless spending, impulsive sexual behavior, impulsive driving, impulsive eating
• Overlap with bipolar disorder, especially bipolar II 
  • Mood changes more frequent in BPD than bipolar II
• Challenges faced by individuals with BPD 
  • Often have multiple mental health problems simultaneously
  • Difficulty maintaining relationships and jobs due to emotion dysregulation 
    • Fear of abandonment, intense emotions leading to lashing out or avoidance
  • Can range from severe problems (unable to work, maintain relationships) to more functional individuals who still struggle with emotional regulation
    Intense Behavior and BPD
• Intense behavior may lead to self-​​injury or suicide threats 
• Mortality of BPD is difficult to determine due to overlapping disorders
• More than 75% of people with BPD engage in self-​​injury or have made multiple suicide attempts

Self-​​Injurious Behavior

• Examples: cutting, burning, head banging, punching, scratching, overdosing, ingesting toxic substances
• Debates on whether certain behaviors, like binge eating, are considered self-injury

Gender Split in BPD

• Previously thought to be a female disorder
• Recent studies show roughly equivalent rates among men and women
• Diagnostic bias may lead to underdiagnosing men and overdiagnosing women

Genetic Link in BPD

• Genetic component to the disorder, but also environmental factors
• DBT framework explains how BPD develops with both genetic and environmental components

Marcia’s Journey

• Obtained a social psychology PhD, then pursued clinical training at Stony Brook
• Attempted to apply CBT to chronically suicidal individuals, but found it insufficient
• Developed DBT through an iterative process, using her own experiences and client feedback
  Dialectical Behavior Therapy (DBT)
• Developed by Marsha Linehan in response to treating chronically suicidal patients 
• Patients felt misunderstood when therapists tried to solve their problems or accept their situations
• DBT focuses on balancing change and acceptance

Dialectics

• Humans don’t like contradiction, but dialectics recognize tension and opposition in everything
• Dialectics involve finding validity in both sides of a tension and seeking synthesis

Wise Mind, Emotional Mind, and Reasonable Mind

• Wise Mind: intersection of Emotional Mind and Reasonable Mind, an example of dialectical synthesis
• Emotional Mind: state in which we are completely controlled by our emotions
• Reasonable Mind: state in which we are controlled by facts and logic, without strong emotions
• Wise Mind involves recognizing the validity of both Emotional and Reasonable Mind and finding a synthesis

Development of DBT

• Linehan realized that pushing for change or acceptance too hard led to disaster
• She sought to find a balance between change and acceptance in therapy

• DBT has evolved over the last 30–40 years and continues to be refined and adapted
  Dialectical Behavior Therapy (DBT) and Radical Acceptance

• DBT developed by Marsha Linehan 
  • Originally focused on cognitive behavioral therapy
  • Incorporated dialectical philosophy and Zen mindfulness practices
• Radical acceptance: accepting the present moment as it is 
  • Can lead to experiencing joy and reducing suffering
  • Helps in dealing with difficult situations and emotions

Applying Radical Acceptance in Difficult Situations

1. Stuck in traffic and running late

• Focus on the present moment 
  • Let go of past decisions and future worries
  • Accept the current situation as it is
• Consider problem-​​solving for future situations 
  • Not during the moment of crisis or high distress

2. Terminal diagnosis

• Acknowledge the reality of the situation 
  • Accept the limited time left and the emotions that come with it
• Focus on making the best of the remaining time 
  • Engage in meaningful activities and relationships
  • Seek support and comfort from loved ones

3. Loss of a child

• Recognize the immense pain and grief 
  • Accept that nothing can bring the child back
• Find ways to cope and heal 
  • Seek support from friends, family, or therapy
  • Honor the child’s memory and find meaning in their life
• Focus on being present for other children and loved ones 
  • Continue to be a supportive and loving parent

Conclusion

• Radical acceptance can help individuals cope with difficult situations and emotions
• By accepting the present moment as it is, individuals can reduce suffering and find joy in their lives
• DBT and mindfulness practices can provide valuable tools for dealing with life’s challenges
  Radical Acceptance and Pain
• Life is full of pain, both emotional and physical 
• Acceptance doesn’t mean not experiencing pain
• Trying to escape pain can cause more problems
• Radical acceptance involves continuously turning the mind towards acceptance
• Refusing to accept can take more mental resources and cause more problems in the long run

DBT and Skills Deficit Model

• People with borderline personality disorder have an absence of certain skills
• Deficits can be due to never being taught, having effective behaviors punished, or not being corrected
• DBT addresses deficits in five domains:
• Mindfulness — being aware of the present moment
• Interpersonal effectiveness — conflict resolution, asking for things, saying no
• Emotion regulation — labeling emotions, managing emotions, preventing extreme emotions
• Distress tolerance — tolerating stressful situations without making them worse
• Self-​​management — doing things you don’t want to do, managing behaviors

Walking the Middle Path Skills

• Part of the adolescent version of DBT
• Teaches adolescents and their caregivers principles of self-management
• Helps manage behaviors and learn more effective behaviors

CBT and Borderline Personality Disorder

• Mixed data on whether the presence of BPD leads to worse outcomes in standard CBT
• Marcia Linehan chose to focus on BPD because she was interested in suicide and suicidal behaviors
• At the time, depression research was already being conducted by many smart people, so she chose BPD as her focus
  DBT (Dialectical Behavior Therapy) for Non-​​BPD Individuals
• DBT was developed for individuals with Borderline Personality Disorder (BPD)
• However, it can be beneficial for those without BPD or depression
• Skills learned in DBT can be applied to everyday life situations
• Even individuals without psychopathology can benefit from DBT skills

DBT Skills and Accessibility

• DBT is designed to be highly accessible
• Uses acronyms, diagrams, and simple language
• Can be learned and applied by anyone, regardless of their background or experience

Dear Man Acronym in DBT

• Dear Man is a skill in the interpersonal effectiveness module of DBT
• Helps individuals ask for something effectively or say no assertively
• Acronym stands for:
• Describe
• Express
• Assert
• Reinforce
• Mindful
• Appear confident
• Negotiate
• Can be used in various situations to improve communication and interpersonal effectiveness
  Vulnerability Factors and Chain Analysis in DBT
• Vulnerability factors: important in understanding problem behaviors 
• Chain analysis: assessing factors, events, thoughts, behaviors leading up to a problem behavior 
  • Identifies elements to modify to prevent problem behavior in the future
• Vulnerability factors can change everything that follows, but sometimes other elements are more critical
• Everything has multiple causes, making it difficult to pinpoint one root cause

Difficulty in Regulating Emotions

• Factors that make it hard to regulate emotions: 
  • Biology: differences in brain structure and function
  • Lack of skill: not taught, good skills pushed away, or bad skills reinforced
  • Reinforcement of emotional behavior: certain behaviors rewarded in specific contexts
  • Moodiness: current mood affects ability to regulate emotions
  • Emotional overload: increased pressure makes regulation more difficult
  • Emotional myths: mistaken beliefs about emotions

Mindfulness and Meditation in DBT

• Mindfulness is central to DBT, but meditation is not required
• Therapists and clients should have a mindfulness practice, but it can take various forms (e.g., yoga, mindful walking)
• Seated meditation can be beneficial but may not be practical for everyone
• Mindfulness skills in DBT are more concrete and practical, designed for use in any moment

Helpful DBT Techniques

• [Expand on specific techniques that the user finds helpful]
  Opposite Action in DBT

• Opposite action is a skill in the emotion regulation module of Dialectical Behavior Therapy (DBT)
• It involves engaging in the opposite of what your emotional urges are telling you to do
• Helps change an emotion that you don’t want to have
• Examples of opposite action:
• When sad, activate instead of withdrawing
• When fearful, approach instead of running away
• When experiencing shame, confront or disclose instead of hiding
• Opposite action can be difficult to execute but becomes easier with practice

Benefits of Opposite Action

• Can help manage emotions like anger, sadness, and social anxiety
• Can lead to positive experiences and personal growth
• Helps send feedback to the brain to feel a different way

DBT as a Skill to Learn

• DBT can be beneficial for anyone, not just those with severe mental health issues
• There is a need for more research on who needs the full package of DBT versus who can benefit from a lighter touch or lower dose
• DBT can potentially be learned through manuals, books, and online videos, but the effectiveness of this approach is not yet fully understood
• A stepped care model of DBT could help identify the most effective sequences of care for different individuals
  DBT (Dialectical Behavior Therapy) Skills and Therapists
• DBT skills can be learned through videos, books, and other resources 
• If struggling to apply DBT skills, consider reaching out to a DBT therapist

Finding a DBT Therapist

• Proceed with caution and research when looking for a mental health provider
• Linenhan Board of Certification (LBC) certifies DBT therapists 
  • Certified therapists are likely good DBT clinicians
  • Not all uncertified therapists are bad DBT therapists; some choose not to go through the certification process
• Start by looking up certified DBT therapists, but don’t rely solely on certification

Determining a Therapist’s DBT Pedigree

• Ask if the therapist is part of a DBT consultation team 
  • Weekly consultation team meetings help therapists improve their adherence to DBT principles and their motivation
  • Therapists who are part of a consultation team are more likely to adhere to DBT principles

Conclusion

• DBT is a vast topic, and this discussion is meant to pique curiosity
• Encourage exploring DBT skills and potentially making it a regular part of one’s training