Dialectical Behavior Therapy (DBT): Emotion Regulation

What is Dialectal Behavior Therapy?

 

Video credit: UCSF

 

Dialectical Behavior Therapy (DBT):

The main goal of Dialectical Behavior Therapy (DBT) is to build a Life Worth Living, a life with things that are meaningful and important to you. One in which you have hope, find pleasure in your day-to-day activities, and have things you are looking forward to.

Understanding the acronym “DBT” provides an insight into what the treatment is. The “D” stands for Dialectical. Dialectics help us to understand that often two things (that can seem like opposites) can be true at the same time. For example, in DBT, we believe everyone is doing the best that they can AND we also believe that they need to do better. In treatment, the therapist balances acceptance (“you’re doing the best you can”, “this is the reality of life right now”, “this is difficult”) with change (“being willing to try things differently will get you the life you want”, “you need to do better, try harder, and be more motivated to change”).

The “B” in DBT stands for Behavior. When we look at behaviors, we are including all actions, thoughts, and emotions. All of these behaviors are caused, and it is more effective to understand and change these causes than to judge or blame.

In DBT, we carefully assess behaviors that need to increase or decrease in order to create a life worth living, one that is meaningful and fulfilling.

We Are Adherent to the Linehan DBT Model

There are many treatments offered under the “DBT label”, but they are of varying quality and often not adherent to DBT at all. This can be extremely confusing for those who are seeking the right help. The Counseling Center Group™ (CCG) maintains adherence to the DBT protocol. At CCG, when we specify Dialectical Behavior Therapy or “DBT”, we are referring to treatment that keeps fidelity to the Linehan model. Adherence and training allows maximum potential for our clients to reach their treatment goals.

The Counseling Center Group™ strives to provide the gold-standard quality of DBT treatment to our clients. We hope to empower you by providing clear guidelines of what to expect from an adherent DBT program and by giving you the proper information in order to identify the treatment that best works for you.

Who can benefit from Comprehensive DBT Programs?

Originally, DBT was created by Dr. Marsha Linehan as a highly effective treatment for individuals living with Borderline Personality Disorder. DBT became a widely used treatment for individuals with a history of multiple past hospitalizations or for those who have tried therapy many times and haven’t had any success. DBT is also proven to be an effective treatment for individuals who have difficulty regulating extreme emotions, experience low self-esteem, have patterns of unstable relationships, and engage in impulsive or self-destructive behaviors.

Those who would benefit from DBT may be struggling in five areas of dysregulation:

  • Emotional dysregulation: emotions can become overwhelming, moods can change quickly and feel uncontrollable, outbursts of anger can occur, and intense feelings of sadness or fear may be experienced.
  • Behavioral dysregulation: this response to emotional suffering may bring on powerful urges to self-harm or engage in impulsive behaviors. These behaviors may result in drug and alcohol addiction, out of control spending, regular gambling, binge eating, reckless driving, acting out or unsafe sex.
  • Interpersonal dysregulation: going back and forth between love and hate in close relationships that may be turbulent. A deep fear of being abandoned, leading to frantic attempts in hopes to salvage a relationship.
  • Cognitive dysregulation: stressful experiences may cause hyper-vigilance or dissociations. Beliefs, often incorrect, related to the intention of others. Feeling spaced, emotional numbness, or feeling like you are observing life from a distance may occur.
  • Dysregulation or fragmentation in one’s sense of self: Feeling empty, unsure of your identity or wondering if an identity even exists. Changing yourself in your personality, presentation, and values, according to the people you’re with at the moment. Feeling like you may not even exist may be experienced.

DBT also effectively treats a variety of diagnoses and symptoms including:

  • Emotion and/or Behavioral Dysregulation
  • Bipolar Disorder
  • Major Depression
  • Binge Eating Disorder
  • Suicidal and Self-harming Behavior
  • Bulimia Nervosa
  • Substance Use Disorder
  • Self-destructive behavior
  • Attention Deficit Hyperactivity Disorder (ADHD)
  • Ongoing relationship conflicts
  • Post-Traumatic Stress Disorder (PTSD)
  • Anger management problems
  • Borderline Personality Disorder (BPD)
  • Anxiety
  • Depression
  • Impulsivity
  • Low self-esteem, and more.

Four Components of a DBT Program:

We offer a comprehensive DBT Program that is adherent to the Linehan Model of DBT. A true DBT program requires participation in all four components of comprehensive DBT:

  • Weekly Individual Therapy
  • Weekly DBT Skills Training in a group setting
  • Phone Coaching between sessions
  • Therapist participation on a Consultation Team

WEEKLY INDIVIDUAL THERAPY

Weekly individual therapy focuses on assisting you with the application of learned skills to specific challenges and situations in your life. Your motivation will be enhanced, enabling you to apply the skills to your day-to-day life.

A variety of tools are used in individual sessions such as Diary Cards and Behavior Chain Analysis, with the aim to reduce behaviors that negatively impact your life, and most importantly, provide a path to your Life Worth Living Goals. DBT focuses on creating a target hierarchy to reach those goals and to build awareness of the connection between thoughts, emotions, and actions.

DBT PHONE COACHING BETWEEN SESSIONS

Phone Coaching is an integral part of DBT, enabling you to generalize the skills you have acquired into your life. The goal is to provide coaching to you on using skills when you need them most: in your day-to-day life. It provides in-the-moment support by phone, text, email or some other form of electronic communication. Your therapist is available between sessions to guide you in the use of skills learned in therapy. This enables you to receive coaching on relevant skills and how to use them in specific situations in your life, and maintain lasting treatment gains. Therapy takes place in an environment that is very different from your everyday life. Oftentimes in the very beginning of treatment, clients do not yet have the skills to effectively manage impulse control or regulation. Situations may arise that create a reactivity and that first impulse will usually make things worse. Phone coaching helps to alleviate this in the beginning.

Benefits of Phone Coaching

  • Generalize skills from therapy to the natural environment
  • Avoid short-term problems and avoid making already stressful situations worse
  • Ongoing support and connection
  • Helps you to learn to ask for and receive help

Early in treatment, you will be oriented to phone coaching along with how and when to use it effectively.

THERAPIST PARTICIPATION IN DBT CONSULTATION TEAM

The structure of DBT provides a community of therapists supporting a community of clients. DBT consultation team is meant to be “therapy for the therapists”,utilizing the same DBT strategies and principles in order to support them in their complex work. The consultation team is designed to help DBT therapists maintain motivation, continually increase competency and adhere to the treatment protocol. Thus enabling the best possible treatment for their clients. DBT consultation teams meet weekly and consist of individual therapists and group leaders who are responsible for every client’s treatment and care.

DBT SKILLS TRAINING GROUP

DBT skills group will enhance your capabilities by providing you with practical skills that will help you create stronger relationships, build self-esteem, effectively problem solve, set and achieve your goals, and rediscover hope. Problematic behaviors are a way that we all cope with a situation or attempt to solve a problem. While these behaviors often provide temporary relief, they often are not effective in the long run. Skills groups are structured like a class, where skills are taught and homework is provided to be practiced outside of the group. Practicing the homework regularly will enable you to access skills in day-to-day life when you most need them.

DBT Skills Groups Covers Four Modules:

  • Mindfulness Skills
    • The practice of being fully aware and present in our lives.
  • Distress Tolerance Skills
    • How to tolerate emotionally painful, uncomfortable, and difficult situations. In addition, improving the ability to accept reality as it is.
  • Emotion Regulation Skills
    • Teaches how to understand and manage overwhelming emotions, along with improving the ability to decrease uncomfortable emotions and increase pleasurable ones.
  • Interpersonal Effectiveness Skills
    • How to maintain self-respect and develop strong relationships, while asking for what you want and creating healthy boundaries.

What is the time commitment of the DBT skills group?

To cover all four modules of the DBT skills work, it typically takes 6 months time. This is considered one full “cycle” of DBT. Some clients benefit from completing two cycles of DBT Skills Training in order to thoroughly master the skills.

How to Identify DBT Programs That Aren’t Adherent to the Linehan DBT Model:

Given the strong empirical foundation of DBT, many clinicians want to incorporate DBT skills into their therapeutic work. However, DBT programs are complex and require maintaining fidelity to the Linehan model, which demands extensive training, time, effort, and dedication to the adherent model. A wide variety of treatments are offered under the DBT “label”, however, many are not actually providing DBT, but rather small components of a very complex treatment. This is confusing at best, and oftentimes fraudulent. A comparable analogy would be a primary care physician performing open heart surgery with no specific training to do so (only reading about the procedure), but advertising oneself as an expert in it.

A Fully Trained DBT Therapist Should Say ‘YES!’ To All of The Following Questions:

  • Were you intensively or foundationally trained in DBT through Behavioral Tech?
  • Are you currently a member of a DBT Consultation team with other intensively trained DBT therapists, following the Linehan model for DBT Consultation teams?
  • How often are you continuing your DBT training and education through Behavioral Tech or the Linehan Institute?
  • Do you use Diary Cards in every session?
  • Do you practice Behavior Chain Analysis?
  • Are you supervised by an experienced DBT therapist?
  • Are you a DBT-Linehan Board of Certification, Certified Clinician™? If not, do you have one on your consultation team?
  • Does your DBT program incorporate the four components of DBT, each provided adherently:
    • Weekly Individual Therapy
    • Weekly DBT Skills Training in a group setting
    • Phone Coaching between sessions
    • Therapist participation in DBT Consultation Team

Indicators that you are NOT in a DBT program: You are not in a DBT program if your therapist is working with you to eliminate some of your emotions, (ie: “I want to get rid of my anxiety”). Emotions in and of themselves are not problematic. The goal of DBT is to change our relationships with our emotions, not eliminate them! Our emotions have important functions: they communicate to ourselves and others and they prepare us for action. Our focus in DBT is to relate to our emotions in the ways they were intended, to be able to tolerate uncomfortable emotions and to increase the frequency of pleasurable emotions.

You are not in a DBT program if your therapist uses words such as manipulative, attention-seeking, or other judgmental languages to describe your behaviors. In DBT we understand that we all have the behaviors (actions, thoughts, emotions) that we do because they have worked for us in the past. A DBT therapist will describe these behavioral patterns clearly, and with precision. By understanding these experiences in detail, we can gain insight into the solutions needed to provide you with relief and ultimately build a Life Worth Living.

You are not in a DBT program if your session DOES NOT begin with a review of your diary card, followed by setting an agenda from that diary card. The structure of a DBT session keeps the treatment moving toward your goals. Without such structure, it would be easy to fall into a cycle that resembles the game Whack-a-Mole. DBT is a relatively short-term treatment. The structure in sessions keeps you on track to accomplish the very things you came to therapy for!

You are not in a DBT program if you go to therapy and feel like you have the space to vent about your week, you feel validated, but nothing is changing. In DBT we balance acceptance techniques (validation) with change strategies. If a therapist is only focused on acceptance, it can feel good, but nothing changes. If a therapist only focuses on change, you will likely shut down and feel unheard.

You are not in a DBT program if you are not learning about clear patterns in your behaviors (actions, thoughts, and feelings). In DBT we help you to understand what events prompt your behaviors, what makes you more vulnerable to them in the first place, and how they are reinforced (which leads to ongoing patterns). Along with that, together you will look at the entire chain of events and collaborate on alternate options.

DBT THEORY AND BACKGROUND

Dr. Marsha Linehan, the creator of DBT, researched chronically depressed clients struggling with suicidal ideation and frequently experiencing emotional dysregulation. Existing CBT treatments and person-centered approaches were proving to lack effective and long-term results for this group of patients, so Dr. Marsha Linehan set out to discover a new treatment modality that would create positive change in these clients’ lives.

Linehan reviewed the existing Behavior Therapy (BT) literature to note which techniques were successful in effectively regulating intense emotional states, including anger, anxiety, depression, and fear. She began by incorporating CBT techniques that proved to be successful tools for emotional regulation. In addition to incorporating emotion regulation skills, Linehan recognized the significant impact of mindfulness and applied it to her treatment research as well.

Dr. Marsha Linehan grouped the tools and techniques that proved to be effective with her clients into a well-organized treatment package. Many of the skills are effective on their own for treating particular challenges clients face, so Linehan felt it would be the most beneficial approach to teach clients how to utilize them all together in order to increase their capability of managing crises and independently resolve a wide array of difficult challenges that may arise in everyday life.

Originally, DBT was created as a highly effective treatment for individuals that have not been responsive to the treatments of the past. DBT became a widely used treatment for individuals with a history of multiple past hospitalizations, or for those who have tried therapy many times and haven’t had any success. DBT is proven to be an effective treatment for individuals who have difficulty regulating extreme emotions, experience low self-esteem, have patterns of unstable relationships, and engage in impulsive or self-destructive behaviors. Although the majority of research trials on the effectiveness of DBT have been on people with complex mental illnesses, there is significant evidence demonstrating that some components of DBT (such as DBT skills) are extremely effective for a wide variety of people, in both a clinical and non-clinical setting. This video clip articulates the benefits of DBT for EVERYONE:

 

At the Counseling Center Group, we offer DBT, and DBT-C, and also offer options such as our Emotion Fitness Program for those clients that do not need comprehensive DBT but would like to benefit from some components of it.

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