Dialectical Behavioral Therapy (DBT) was developed by Marsha Linehan, Ph.D., a professor of psychology at the University of Washington in Seattle. Linehan was prompted in her development of DBT largely by the “limitations” of traditional Cognitive Behavioral Therapy.
What stood out for Linehan was that CBT, in emphasizing change and expectation of change, inadvertantly risked providing an invalidating therapuetic environment, especially when change didn’t happen. So for traditional CBT, change is seen to be more important than validation. From a DBT perspective, where a person was at this moment, makes perfect sense given his or her DNA, history, experiences and circumstances.
DBT was developed with the concept of Radical Acceptance as a centerpiece. From this stance of non-judgemental, unconditional acceptance – actually a stance of friendliness or compassion towards one’s self - Thich Nah Hahn talks about “cuddling” one self – DBT focuses on changing destructive coping methods and developing skills around new ways of thinking and behaving.
The Roots of DBT
DBT draws on several sources. Philosophically, DBT uses the Hegelian dialectic in which opposing things can be true at the same time – “I’m done with relationships, they’re too painful” and “I really need to feel validated & close to someone“. It also draws on Cognitive Behavioral therapy which looks at ways in which thinking distortions can give rise to suffering.
Zen philosophy is a strong thread in DBT with emphasis on Radical Acceptance of what is and compassion towards one’s self. There are also strong existential themes in DBT: Value is important – what do I want for myself? as well as commiting to action in terms of one’s values.
Fundamental DBT Concepts
DBT rests on the deeply rooted presupposition that people are doing the best they can.
DBT takes the perspective that destructive and hurtful behaviors have there own logic. In a very real sense, this is exactly how things must be given the DNA, conditions and history of one’s life as well as one’s current life situation. For example, it makes perfect sense that you feel and act harshly and critically towards yourself, given what you have been through, what you’ve grown up with, coupled with your life circumstances now. Indeed, it makes perfect sense that you still maintain coping mechanisms which might have worked in the past, even though they might not work now – and quite possibly get in the way of what you really values and want for yourself.
People are motivated and willing to change.
DBT takes the position that people get tired of behaviors which continue to produce intolerable levels of suffering. People get tired of endlessly punishing themselves and trying ways of ending pain and suffering as well as destructive patterns on their own. People get tired of struggling and so have a strong and conscious commitment and intention to change.
Radical Acceptance is the foundation of transformation and change.
DBT takes the position that before you can move towards positive change or action in support of your values, you must accept yourself without judgement or criticism or blaming. Radical Acceptance then is intimitely connected with compassion and a friendly accepting attitude towards yourself. DBT puts a premium on being with “what is” – without judgment or an attempt to get away or make it different - which at the heart of Mindfulness practice, a core skill in DBT.
This is not the same as passively accepting “whatever” and doing nothing to serve one’s values. Rather, Radical acceptance allows one to move beyond suffocating stories of blame and self-loathing, by seeing the pattern of blame and loathing for what it is.
For example, every time Julie loses a relationship, she criticizes herself for messing up, panics at the thought of being alone. Sobbing and terrified that she will be rejected again she finds herself entangled with thoughts that she needs to rush into another relationship. So she not only feels the pain of ending the relationship but also the shame of being so vulnerable to messing up.
Using DBT skills of Mindfulness and Radical Acceptance, Julie comes to appreciate her reaction simply being what it is, without judgement and shame. “This is simply what I do given my DNA, my history the conditions of my life and so on”. Once she releases herself from self-criticism and judgment, change is possible.
One of the deepest forms of suffering in our culture is the pain of feeling that “something is wrong with me.” Radical acceptance is the capacity to see clearly what is happening in the moment, and to accept what we see with love.
That acceptance of what is present is the ground from which transformation is possible, is echoed by Thich Nhat Hanh who put it this way: “There is the mud, and there is the lotus that grows out of the mud. We need the mud in order to make the lotus”.
Mindfulness is central to Regulating Emotions.
Uncomfortable and painful emotions can be overwhelming and become dysregulated. Dysregulation happens when these emotions trigger behaviors which are directed on getting away from and escaping the painful uncomfortable emotions.
These attempts at experiential avoidance - attempts to reduce or avoid the discomfort and pain, actually increase its intensity.
Mindfulness allows for awareness of the emotions and feelings without attempting to escape or get away. By bringing awareness to the moment, you are able to observe and inhabit the moment, with great precision. This takes a willingness to slow down, to connect with one’s breathing and one’s feet on the ground.
It becomes clear that so much suffering is due to our getting entangled with thoughts and judgements, mostly 
from the past or future – and which lift us out of experiencing the present.
For example, Steve lies awake at night anticipating the reaction of his boss to his presentation to the group. His stomach tightens at the prospect of “messing up”. He notices the tightness in his stomach and the stream of thoughts about previous “situations of messing up” and he allows the thoughts to float by, comforted by the deep sense that he will do his best and that it will be quite okay not to “be perfect”.
The Heart of DBT is Skills Training
DBT takes some dedication as well as commitment to learning and practicing new skills. Homework is always assigned and an important element is using the skills outside the session.
Skill-training integrates four interrelated modules: distress tolerance, core mindfulness, emotional regulation, and interpersonal effectiveness.
Distress tolerance module
Frequently, attempts at experiential avoidance - attempts to reduce or avoid discomfort and pain, actually increase its intensity. DBT skill training encourages observing and describing emotions as physical sensations in your body, as well as noticing assumptions, beliefs and judgments about the situation – the stories which go on in your head – which affect how you react to the situation.
DBT skill training also offers down to earth and practical ways of acting to make uncomfortable, painful and crappy situations more tolerable. For example, the grief and pain following the loss of a relationship might be alleviated and soothed by crying, eating something delicious, talking to friend and a taking warm bath.
Emotional Regulation module
It is well established that emotional arousal affects what one does and how one thinks. Research from about one hundred years ago points out that while low or moderate amounts of stress and arousal help keep one focused, alert and on task for example, a job interview or making a presentation – however, when the arousal increases beyond a moderate level, reactions change dramatically.
When the emotional system becomes dysregulated, it gets in the way of being able to respond effectively to the situation.
The goal of the emotion regulation then is decreasing the intensity of your emotion. This is not the same as ignoring, avoiding or attempting to make the emotion go away. Rather, the skills help regulate and modulate anger, fear, shame, and sadness.
Interpersonal effectiveness module
The interpersonal effectiveness module is designed to make interpersonal relationships less chaotic and stressful by building skills which support behaviors and actions in support of your values.
Interpersonal skills are central and focus on areas such as:
*identifying and expressing one’s needs in an effective way;
*complaining and making requests effectively;
*supporting and maintaining relationships;
*setting effective limits in relationships.
Integrating DBT with Acceptance and Commitment Therapy – a strong synergy
Over the past several years, I’ve been teaching DBT skills with individuals as well as couples. I have also been integrating DBT skills with Acceptance and Commitment Therapy (ACT).
(Click on) Acceptance and Commitment Therapy (ACT): In a nutshell
My experience has been that the two approaches work synergistically together – each makes the other more effective.
Further rescources
www.lotusinthemud.typepad.com/
Behavioral Technology Transfer www. behavioraltech.com