The Power of DBT: The Beauty of Simplicity and Practicality

Posted by Peter Allen, MS, LPCI, NCC on November 15, 2013

Recently, I have been incorporating Dialectical Behavior Therapy (DBT) with the students. DBT as a treatment method was conceived and developed by Marsha Linehan, who was at different times in her life diagnosed as having both schizophrenia and borderline personality disorder. Despite being committed to a secure psychiatric facility, several suicide attempts, and her very real mental health challenges, she was determined to develop treatments to help those who suffered as she did. She eventually earned her doctorate and became a clinician and researcher. For more on Dr. Linehan’s personal story, you can read this New York Times article on her from 2011:

In my opinion, what makes DBT so compelling is both its origin story and its beautiful blend of simplicity and practicality. The dialectical aspect refers to the fact that the therapist’s role is to promote acceptance (and therefore client buy-in and alliance) while also encouraging change. This isn’t pie-in-the-sky therapy; these are very practical measures any person can undertake to improve their lives and emotional state in a very real sense. I’m going to talk about DBT’s four essential modalities, and why having treatment focused on these principles truly works. This is by no means a complete description of DBT; that would require much more space to explain adequately. This is merely a summary of the basic skills involved. While Dr. Linehan developed these methods for treating clients with borderline personality disorders that were much like her, this style of therapy can also be effective in treating a wide range of other psychological issues.

Dr. Linehan was inspired by her own spiritual experiences, and by Eastern traditions such as Zen Buddhism and meditation. As such, the first of her four modalities is mindfulness. Through the conscious and deliberate practice of becoming more mindful, we all become more aware in the moment of our emotional states, our inner dialogue, body sensations, and triggers. We learn to recognize and assess our own state, whatever that may be. We have to recognize and accurately appraise the current situation before we can hope to improve upon it. Mindfulness is at the very core of this treatment. Have any of you ever asked a teenager: “what were you thinking?” Most of the time, they cannot answer that question accurately.

Another aspect of DBT’s approach is known as interpersonal effectiveness. This is all about communication. In other words, how can I effectively communicate my present state and needs without jeopardizing my own or anyone else’s emotional safety? We tend to think of CEOs and successful business people as being “effective” people; this usually means that we perceive that they are adept at getting what they want. This is part of interpersonal effectiveness, but I think of it more as being the art of how to say what you mean and mean what you say. It is about resolving conflicts without having to “win” and without trying to make the other person “lose.” It is about how to describe how we are feeling and truly talk about ourselves and our experiences, rather than blame someone else for how we feel. It is about navigating the daunting and complex world of human relationships without losing our sense of self. It is about the knowledge that just because you are having a bad day, it doesn’t mean that I have to have a bad day.

Moving along, we come to the third central concept in DBT: emotional regulation. Most of us have experienced times when we regulated our emotions very well, and other times when we did not. Teenagers tend to specialize in NOT regulating their emotions, as many of us have observed. If any of you have ever hit a wall (or a person, for that matter), then you have experienced a lack of emotional regulation. That is to say, your emotions regulated you and your behavior. So the question is: are we in charge of our feelings, or are our feelings in charge of us? Emotional regulation as a skill encourages us to try to be in charge, but also admits that there may be times when we are not. That is where mindfulness can really help us out; if we are aware that our emotional state is not very well regulated in the moment, we can often prevent ourselves from making a poor decision in the moment. Feelings are not the problem; the decisions made based on feelings we have are usually the problem (think of drug use when one is depressed). Did you ever know someone who made a wonderful decision in the moment while they were incredibly angry? Me neither. I talk to my students about our emotions being like the current of a river… there are times when the current is very strong, and times when it is not so strong. What I ask my students is this: are you in the current up to your ankles, knees, waist, chest, or are you tumbling through the whitewater of your emotions? Are you sitting on the banks of the river, calmly watching the current go by or are you being swept away by it? Can you articulate how much control you have in the moment? With practice over time, we can all learn how to get swept away by the current with less frequency and for a shorter duration of time.

Finally, the fourth concept in DBT is distress tolerance. This is exactly what it sounds like: an ability to handle discomfort, challenge, and hardship. Distress tolerance is exactly what many people with a substance abuse problem are lacking. Most parents with whom I have worked will openly say their teenager has a low distress tolerance. That is, when hardship or adversity arises, the teenager is searching for an escape route rather than trying to overcome the difficulty. Does this sound like anyone you know? In our line of work, hardship mostly looks like emotions: sadness, anger, anxiety, or hopelessness, to name a few. Again, in the example of substance abuse, usually a teen is taking a chemical to avoid feeling a certain way. It might not be drug use; maybe he or she is engaging in a manipulative behavior to change the feeling in the moment. In both cases the teenager successfully avoids whatever is difficult. The problem with this strategy is that the world is full of real hardship. DBT argues that it is better to learn how to deal with it, because it is inevitable. As one of my colleagues puts it, cultivating distress tolerance helps the students learn “how to be comfortable with being uncomfortable.” Remember, the feelings aren’t the problem, the decisions and behaviors are. When we learn to sit with our feelings, we develop resiliency and an increased ability to overcome adversity. We are literally rewiring our brain on a physical level for success.

To put this all together, I invite you to think of these DBT skills in relation to your child. For me, these principles are wonderfully clear, concise, and practical. I love incorporating these simple yet effective skills into my work with teenagers. Practicing mindfulness helps us all understand what we are feeling, thinking, and experiencing in the moment. Developing interpersonal effectiveness helps us to communicate our experience, our needs, our wants, and allows us to take ownership and responsibility for ourselves, our feelings, and our actions. The skill of emotional regulation encourages us to not get swept away in the current of our emotions- and if we are swept away momentarily, then we put off making a decision until we are more centered and stable. Cultivating distress tolerance helps us remember that this too shall pass, and the old axiom that we usually meet our fate on the road we take to avoid it. We are better off working through something than we are working around it.

Dr. Linehan was fond of references to what she termed the “wise mind.” That is the point that is exactly halfway between our cognitive, rational selves and our emotional selves. When we make decisions, no matter how big or small, we are aware of our feelings as well as the logical reasons for any choice. We want our teenagers to acknowledge their feelings and work through them; we also want them to weigh the pros and cons of their choices, make calculations, assess risk, and project possible outcomes.

May we all find a way to access our wise mind.

If you’d like to see video of the great Dr. Linehan, there is so much good footage out there for you to find. Here is a more recent one of her being interviewed about DBT.

My sincere thanks for your attention and mindfulness,

Peter