DBT evolved out of Cognitive Behavioral Therapy (CBT). CBT challenges clients to change the way they think in order to change their emotions and behaviors. In the 1970s, Dr. Marsha Linehan noticed that clients found the focus on change invalidating, especially clients who were suicidal or self-harming. So she and her colleagues developed DBT, which balances acceptance and change or mindfulness and skills.
The New York Times ran a poignant story about Linehan’s personal journey to DBT that we highly recommend. Casey Limmer, St Louis DBT, LLC’s founder and owner as well as one of the first nationally certified DBT clinicians in the country, describes what led her to DBT in her profile.
What Differentiates DBT
DBT brings together acceptance-focused mindfulness traditions present in Eastern and Christian contemplative traditions with change-oriented CBT strategies. DBT is based on dialectics — the synthesis of seemingly opposite forces, like you may not have caused your situation but you are the only one who can solve it. DBT considers anything a person thinks, feels or does to be behavioral. The emphasis on validation differentiates DBT from many other therapies. Behavior chain analysis is unique to DBT. DBT evaluates clients based on their stages of treatment as follows:
- In Stage 1, the client is miserable and their behavior is out of control: they may be trying to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviors. When clients first start DBT treatment, they often describe their experience of their mental illness as “being in hell.” The goal of Stage 1 is for the client to move from being out of control to achieving behavioral control.
- In Stage 2, they’re living a life of quiet desperation: their behavior is under control but they continue to suffer, often due to past trauma and invalidation. Their emotional experience is inhibited. The goal of Stage 2 is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) is treated, if present.
- In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and find peace and happiness. The goal is that the client leads a life of ordinary happiness and unhappiness.
- A fourth stage is needed for some people: finding a deeper meaning through a spiritual existence. Linehan has posited a Stage 4 specifically for those clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness to a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.
DBT has four components: therapy, skills group, coaching calls and consultation. The objectives of these components are to learn and apply skills until they become increasingly automatic in all (or most) areas of your life (e.g., home, school, work, social situations, friendships and intimate relationships).
In individual therapy, you will apply skills to current situations, track your progress and enhance your motivation. There are two aspects to individual therapy: what we do in DBT individual therapy and the relationship between client and therapist.
Things You Can Expect in Therapy
Review Diary Cards. Each week, you will complete a diary card, monitoring your emotions, urges and actions and identifying the DBT skills you used to address them. Your diary “card” may be a paper card or an app on your phone, or laptop.
Behavior Chain Analysis. Focusing on current problems, you will learn to effectively and non=judgmentally analyze your problem behaviors and come up with practical solutions.
Skills Application. Each week, you will talk about and practice skills learned in DBT Skills Group. You will be given homework to practice skills in different areas of your life. The goal is to practice until skills become almost automatic.
Establish Behavioral Targets. As you move through the four stages of DBT treatment, you and your therapist will establish behavioral targets. You will monitor urges and responses that lead you closer to or further from achieving your behavioral targets weekly. In Stage 1 (where many clients begin), targets are prioritized from self-harming behaviors to therapy-interfering behaviors to quality of life interfering behaviors. Learn more about stages and targets at the Behavioral Tech FAQ entitled “What are the top targets and goals of treatment in DBT?”
Monitor Progress. It is important to monitor (and celebrate) how far you have come from time to time. Knowing how far you have come reinforces confidence in DBT’s effectiveness and enhances motivation to stay the course.
Support-oriented: The therapist helps clients to identify their strengths and build on them so they can feel better about themselves and their lives. In part, the therapist does this by modeling validation.
Cognitive-based: DBT helps identify thoughts, beliefs, and assumptions that make life harder: “I’m not good enough.” “If I have emotions, I’m a weak person.” This helps people learn different ways of thinking that will make life more bearable: “I am good enough in most areas of my life. I deserve to be treated well.” “Everyone has emotions. It’s not a weakness but a sign of strength that I can express them.”
Behaviorally-focused. in 1993, Marsha Linehan wrote, “the therapist actively teaches and reinforces adaptive behaviors, especially as they occur within the therapeutic relationship. . . The emphasis is on teaching clients how to manage emotional trauma rather than reducing or talking them out of crises.”
Collaborative: You will be asked to complete homework assignments, role-play new ways of interacting with others, and to practice skills such as stopping obsessive negative thoughts. It is in this collaboration that lives improve.
Skills groups function like a class where the group leader teaches skills and leads practice exercises to help you use the skills at home, school, work and social situations. Group skills training is not group therapy.
Module-Based Skills Groups
We offer module-based skills groups for adults, young adults and teens with a parent. Up to eight clients meet weekly for 1.5 hours to learn and practice DBT skills. Clients are required to be in individual or family therapy. Classes are organized in four modules:
Core mindfulness teaches you to observe, describe and participate in the moment, nonjudgmentally and effectively.
Distress tolerance teaches skills to tolerate situations beyond your control and emotional crises while you are too upset to use other skills.
Emotion regulation teaches skills to keep emotions from becoming overwhelming or out-of-control.
Interpersonal effectiveness teaches skills to be effective in relationships with intimate partners, friends, family, supervisors, co-workers and the people you interact with casually on a daily basis.
With six sessions per module, it takes 24 sessions, over roughly six months to complete all skills classes. New members can join anytime. Most clients take the four DBT modules more than once to more fully absorb and apply the skills as they become increasingly automatic in most areas of your life. A typical course of treatment takes one year.
Other Skills Groups
Couples DBT is offered twice a year. Couples must join the group at the beginning of a 12-week group. Couples do not need to be in therapy to participate. Weekly sessions last two hours. Sessions are organized by relationship goals. Skills needed to achieve those goals are presented.
Advanced DBT Skills Group is made up of clients who have “graduated” from DBT skills group but want to continue to practice and develop their skills. The advanced group is facilitated by a therapist but largely peer led. Each session focuses on skills needed to address a common problem its members identify. New members may join at any time.
The Mindful Way Through Depression is an 8-week experiential class. The class combines mindfulness meditation and elements of CBT to reduce negative thinking, which research indicates is one of a few manageable factors that cause recurrent depression.
In DBT, clients may call their therapist between sessions in certain situations. These are 5-10 minute calls to help you use your coping skills when you are overwhelmed by thoughts, emotions or destructive urges before the problem behavior occurs. You call your individual therapist as needed or your therapist may ask you to check in at certain times when you are at particular risk. Coaching calls are not intended to be phone therapy.
Your therapist consults with a team of DBT therapists to ensure you get the best care possible and to address your therapist’s need for support and encouragement. We consider this time “therapy for the therapist” and it keeps your therapist working according to the DBT model.
For more information about DBT, go to Marsha Linehan’s website.