How Does Dialectical Behavior Therapy Work?

Written by Jennifer Leydecker, LMFT, Licensed Marriage and Family Therapist

Dialectical Behavior Therapy (DBT) combines behavioral science with mindfulness concepts to help people who have difficulty regulating emotions.

DBT has been found effective for a range of mental health conditions and issues, including depression, self-harm and suicidal ideation, post-traumatic stress disorder, anxiety disorders, eating disorders, impulse control disorders, and others.

Understanding How DBT Works: Acceptance and Change

Dialectical means that multiple opposing perspectives can be true at the same time. The main dialectic in DBT holds that both acceptance and change are needed to move forward.

DBT encourages clients to set the direction for their treatment and feel more invested in the process, allowing for a sense of agency and increasing their commitment level. The stakes are high: as a clinician within the Intensive Outpatient Program setting, I have 12 weeks to support DBT skills development as a means of stabilizing life-threatening behaviors.

The 4 Modules of DBT

There are four modules in DBT: Mindfulness, Distress Tolerance, Emotion Regulation and Interpersonal Effectiveness. Let’s explore the purpose of each:

Mindfulness

Mindfulness involves learning to be fully present in the moment without judgment. This module helps individuals develop awareness of their thoughts, emotions, and physical sensations as they occur.

Emotion Regulation

Emotion Regulation focuses on understanding and managing intense and often overwhelming emotions. This module helps individuals develop healthy emotional responses, reduce impulsive reactions, and prevent emotional crises.

Interpersonal Effectiveness

Interpersonal Effectiveness teaches individuals how to navigate and improve their relationships with others. This module covers communication skills, assertiveness, setting boundaries, and making requests.

Distress Tolerance

Distress Tolerance skills help individuals cope with crises and situations they cannot change immediately. This module provides strategies for tolerating emotional pain and distress without resorting to impulsive or self-destructive behaviors.

Making Assumptions

At the start of each module, we discuss some of the core components and assumptions of DBT to help set the tone for treatment going forward. The core assumptions I find most adolescents connect with are:

1. Everyone is doing the best they can.
2. They want to improve.
3. They need to try harder, do better, be more motivated to change.
4. We may not have caused our problems and we need to find a way to solve them.

DBT skills allow clients to problem-solve while balancing the dialectic of change and acceptance.

Problem Solving with DBT

The four options that DBT presents for dealing with a problem offer a useful roadmap. These options are frequently called upon as we address life-threatening behaviors and those that  interfere with daily functioning and contribute to thoughts of dying or hurting oneself. They include:

1. Solve the problem.

While this may sound simple, in fact there are a lot of factors that may have contributed to the problem to begin with and thus can lead to significant unpacking and problem analysis.

I spend a lot of time identifying the problem as sometimes it is deceiving, wrapped up in layers that we need to decipher before we can work to identify all the possible solutions.

We bring in the concept of dialectics when we are trying to solve the problem, looking at what information we may be missing, for an alternate perspective or kernel of truth for the other side and most importantly, removing our judgments, interpretations and blame.

Once we have gotten down to the facts of the situation, we are then able to use some of our problem-solving skills to look at as many possible solutions as we can, identify pitfalls and make a plan.  This includes rehearsal and emotional preparation for having those difficult conversations, to ensure we are effective and prepared for whatever might come our way.

We also practice more effective behaviors and establish successes along the way to help develop and reinforce the skills we are learning.

2. Feel better about the problem.

This begins with just knowing what we are feeling. Our days are fast paced with expectations and interactions where we are constantly moving from one moment to the next.

I have found that in order to be more efficient, we sometimes push our emotions down as we have learned not to trust them or believe they get in the way of doing what is expected.

While that may work in the short term, longer term those emotions build up or come out sideways and we have not developed the skills to manage them in the moment.  Thus the first step of feeling better is recognizing and validating your own emotions in the moment.

Practicing mindful awareness of our emotions can be incredibly helpful in recognizing our internal signals when we are experiencing specific emotions. We learn to recognize what behavior the emotion is triggering, such as, yelling, running away, staying in bed or engaging in self-harm. There are times when our emotions are bigger than we can move through, so learning how to tolerate them in order to get to a point where our brains can help us problem-solve is critical.

Other times we use skills to recognize the facts of a situation and choose an effective behavior that will be beneficial in both the short- and long-term.

3. Tolerate the problem.

Sometimes the reality of our situation is one that causes us great pain and suffering, or our emotions are so high that we cannot seem to see outside of the swirl of thoughts or anguish we are experiencing in the moment.

DBT offers skills to help in those crisis moments when we can’t seem to make it through another moment of pain and helps us accept the reality of our current situation, our past and/or our future.

Radical acceptance, recognizes that there are situations where we cannot change the facts of that situation. Working to radically accept the facts, (e.g., a past experience that continues to cause suffering) can help us move through the misery we experience from fighting the reality and decrease those overwhelming emotions so we can create the space to envision a life worth living.

We recognize that there is pain in living, we each experience loss, failure and other forms of physical and emotional pain, and by accepting this, we can see that life can be worth living even in those moments of pain.

4. Do nothing; stay miserable.

Most adolescents come to CHC’s RISE Intensive Outpatient Program (IOP) at a really dark time in their lives. Misery is a familiar feeling and can in some cases feel like a warm blanket; the pain they know is easier than the pain they don’t know.

While each adolescent that joins the RISE makes a commitment to do the work to move away from engaging in self-harming and suicidal behaviors, there are times where “doing nothing” seems easier than the work that needs to be done to move through the misery and make changes. But most people do want to feel better, and the “do nothing” option can serve as a motivator.

Once we choose one of these options as our desired outcome, we can then learn and practice the appropriate DBT skill(s) to get us there.

Building a Life Worth Living with DBT

Along my journey as a DBT clinician, I have found these problem-solving options helpful in supporting adolescents and families as they work through factors that interfere with communication, emotion regulation and navigating daily life. Feeling validated and supported where they are while also offering opportunities for change and acceptance seems to move most dedicated adolescents to a place where they are willing to do the hard work and see shifts toward more effective behaviors, realizing their own life worth living. And at the end of the day, what matters more than that?

CHC’s RISE Intensive Outpatient Program

In May of 2017, CHC opened its doors to RISE, an Intensive Outpatient Program (IOP) for teens ages 13-18 who have suicidal thoughts/behaviors, recently attempted suicide, and/or repetitively engage in self-harm behaviors. In 2018, CHC joined forces with Stanford Children’s Health to increase capacity and complement expertise.

The primary goal of RISE has always been to address symptoms of severe anxiety and depression in order to reduce suffering, suicidality and self-harm. Currently, dialectical behavior therapy (DBT) is the only well-established, evidence-based treatment for decreasing suicidal thoughts or self-harming behaviors in youth. As a member of the founding team, we knew from the start we wanted nothing less.

DBT-informed treatment

CHC also offers DBT-informed treatment, which incorporates some components and principles of DBT but does not include all of the features necessary for a comprehensive DBT program. Learn more about the difference between comprehensive DBT and DBT-informed treatment.

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About the Author

Jennifer Leydecker, LMFT, has training in supporting LGBTQ youth, managing difficult behaviors of tweens and teens, depression, anxiety, self-harm, crisis intervention, substance abuse and trauma focused therapy. A licensed Marriage and Family Therapist, Jennifer has over 10 years of experience working with youth and families in both school and outpatient settings in the Bay Area.

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