Dialectical Behavioral Therapy

What is Dialectical Behavioral Therapy?

DBT, or Dialectical Behavior Therapy, is a treatment designed to help emotionally sensitive individuals develop skills to cope with life’s stresses. DBT skills specifically target impulsive behavior, emotional dysregulation and harmful thinking patterns. DBT has been shown to be effective with people suffering from depression, anxiety, eating disorders, obsessive thinking, relationship difficulties, self-harm, poor anger management, and attention deficit disorder. DBT was originally developed to help clients with Borderline Personality Disorder.

What does dialectical mean?

Dialectical refers to the type of strategy or approach used with clients. To approach something dialectically means to establish truths on both sides rather than disproving one argument; seeking the truth not through black and white thinking but by knowing that both sides are true. Contradictions or opposing ideas can be merged into one truth. Dialectical also refers to a world view or set of assumptions we make about reality. Dialectical perspectives stress interrelatedness and change. In wilderness therapy the idea is not to always maintain a stable, consistent environment, but to be comfortable with change and transition. A dialectical view also directs us to look at clients’ behavior and skill development in the present and in a larger context (home, school, with family).

When Is It Used?

With its strong emphasis on emotion regulation skills, DBT is finding application as a treatment for a wide range of mental health conditions. They include:

• Personality disorders, including borderline personality disorder
• Self-harm
• Post-traumatic stress disorder
• Bulimia
• Binge-eating disorder
• Depression
• Anxiety
• Substance use disorder
• Bipolar disorder

What does DBT look like?

DBT specifically focuses on providing therapeutic skills in four key areas:

• Mindfulness focuses on learning to be aware of one’s thoughts, emotions, physical sensations, and actions- in the present moment- without judging or criticizing themselves or the experience. It is the central skill to DBT that balances the emotional and reasonable mind t achieve wise mind.
• Distress tolerance emphasizes learning to tolerate distress and survive crisis without engaging in impulsive behaviors such as drinking, drug use, binge eating, or over spending.
• Emotion regulation is focuses on enhancing the controlled response to emotions. These skills may be highly effective for individuals experiencing mod swings, intense emotional reactions, depression, and anger.
• Interpersonal effectiveness teaches individuals to get their needs and wants met without sacrificing relationships they are in currently. This skill focuses on assertive communication and defining personal needs and wants.

The four skill areas are fluid and are to be used by individuals at different times. They are not a progress assessment measurement, but rather skills that people may use at different times for different stressors. At Elements we may see a client skilled at emotional regulation but struggling to stay mindful of the present. Or a client who made strides in his ability to regulate his emotions, and after a parent visit experiences significant decline in his ability to do so, thus requiring him to revisit the basic emotional regulation skills. Ultimately, the hope is we are presenting these skills as tools for clients to learn and use to increase their success rate when leaving the program. Below are more comprehensive definitions of the skills as well as ways to implement them into the groups.

Weekly skills training format

The therapists for each group will assign specific clients to run one of the four skills groups each week dependent on what the client is working on or what the group can benefit from as a whole. Mentors are to be an active part of running these skills groups rather than letting the clients plan the groups on their own. The DBT skills groups are focused on teaching skills, not processing therapeutic issues.

During the week, Field Mentors actively use almost every moment and opportunity to parallel when and how to use a DBT skill. This helps the clients actively practice the skill throughout their stay in order to have effectiveness in their future interactions with others. An example of this are the below bullet points.

• Prompt the clients to use the skills. When the clients are experiencing emotional and interpersonal difficulties, coach them through the process of finding and using the appropriate skills. Suggest a particular skill or activity. Ask them what they can do in this situation. For example, ‘You seem anxious, Billy. This would be a great time to try one of the distraction techniques we learned about in group last night.’
• Mentors are encouraged to run activities that utilize the techniques as well. Examples of things done in the past are: Mindful dog, guided meditation, breathing exercises, journal writing, emotional identification through peer feedback, reflective listening, bow drill fire time as a distraction, and creating new coping thoughts.
• Much of the basic communication skills and language use at Elements is easily incorporated into the DBT principles. The I-Feel statement identifies emotions, explores beliefs and thoughts and reflects on the present moment. These are components of emotional regulation, interpersonal effectiveness and mindfulness. Time outs can be used as a distraction technique. The feedback process in part of interpersonal effectiveness and distress tolerance.
• Use events that naturally happen during the week as teachable moments. Skills can be taught at any time and this may be the most effective way to teach new skills. Teaching can happen in the moment, during mentor sessions or focus groups.